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Sticchi et al. Vessel Plus 2018;2:23 I http://dx.doi.org/10.20517/2574-1209.2018.47 Page 7 of 10

VASCULAR ACCESS SITE COMPLICATIONS
[42]
The most used access for TAVI is the femoral one, which represents 70% of the procedures .
The most common complications performing TAVI are the dissection and rupture of the vessels that repre-
sent the vascular route of the valve device, so the vessels of the hip, pelvis, the aorta at the abdominal level
and the aortic arch. Moreover, complications on the puncture site such as hematoma and pseudoaneurysm
[42]
are recurrent . The importance of complications derives from their proven impact on mortality and hos-
pitalization which disposes to further complications [43,44] . From the standardization of the Valve Academic
Research Consortium (VARC) definitions, the assessment of complications frequency is more accurate. The
incidence of major vascular complications is ranged between 10% and 20% while minor vascular complica-
[44]
tions are around 10.2% .
Since the valve is squeezed into the catheter for the deployment, the greater the diameter of the valve, the
greater will be the diameter of the catheter and, therefore, the greater the complications for the trauma of
[45]
the passage of the device inside vessels . In particular, a ratio between the diameter of the sheath and that
of the femoral artery above 1.05 is considered risky, as well as unskilled operator, center with limited experi-
ence, severe calcifications and a sheath size greater than 19 Fr [44-46] .

In fact, in a large European multicentric registry, the prevalent use of the 18 Fr device brings to a consider-
[47]
able decrease of vascular complications, with a 2.9% for the trans-femoral access . The study shows no
difference in vascular complications between the two main devices Medtronic Core Valve versus Edwards
[47]
SAPIEN XT valves with a rate of 2.8% and 3.3% respectively (P = 0.66) . We are dealing with a further re-
duction of complications with the introduction of the new 14 Fr systems.

ACCESS AND BLEEDING
The formation of hematomas and the presence of bleeding at the TAVI access site are common complica-
[48]
tions, estimated between 11% and 18% of patients . As previously stated, complications and therefore also
haemorrhage and hematoma of the access site result in longer hospitalization for their management or for
the treatment of further complications such as infections [47-49] .

Following the reduction of the diameter of the devices and the improvement of the technique and experi-
ence of the operators and centers, there was a decrease in bleeding rates. A prompt management of bleedings
and hematomas is essential, the less severe cases can be solved with adequate compression, possibly under
ultrasound guidance. Hematomas of larger size, due to diagnosed late or creating compression of the sur-
[50]
rounding tissue, must be treated surgically . Finally, in case of adequately early diagnosis and after failure
of a compressive first treatment, endovascular techniques are used through a contralateral femoral access.
These consist in prolonged inflation of a balloon at the level of the hole of vessel wall and in case of failure of
[51]
this approach, angioplasty is performed with the placement of a covered stent .

CONCLUSION
The indications for TAVI are expanding and the always more skilled operators must guarantee the best ap-
proach in terms of safety and procedural success. On the other hand, the devices make important progress
on technical aspects, becoming smaller, with easy delivery, accurate positioning and thus realizing the valve
implantation in a more feasible and effective way.

Access site is one of the main topic to assure the TAVI safety and in order to choose the best approach for
every patient and plan successful strategy of implantation, the preprocedural CT angiography study results
are fundamental. Especially in patients with difficult access, the evaluation of risk factors and the experience