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Sticchi et al. Vessel Plus 2018;2:23 I http://dx.doi.org/10.20517/2574-1209.2018.47 Page 3 of 10
[5]
percutaneously in most of the situations . The puncture for this access must be achieved on the common
femoral artery tract bounded by the inferior epigastric artery and the femoral bifurcation, this is pivotal for
functioning of the potential suture-mediated closure devices. The most recent and widespread sheaths have a
size between 14 Fr and 20 Fr and they require femoral arteries of at least 6-6.5 mm of diameter and deposits
of calcium and curves of mild-moderate but not severe degrees. After gaining access, the procedure con-
tinues by sliding the device upwards through the entire aorta until the valve plane is reached as previously
programmed. Once the position is verified intraoperatively, the deployment of the valve, that is crimped in-
side the catheter, takes place either by inflating a balloon inside it or by slipping out of the catheter with the
[13]
self-expanding valve structure . To optimize this placement, the ventricle is stimulated at a frequency of
180-200 bpm to lower the cardiac motion. After positioning the valve, the device is carefully pulled out, the
anticoagulant is reversed and the entry breach is closed. In patients with severe atherosclerotic disease char-
acterized by multiple critical stenoses, large calcium plaques and forbidding angles, the use of femoral access
is unnecessarily risky and harmful, and we can affirm the same for aneurysmal pathology. In these cases,
[8]
it is important to study solutions using other possible ways to accomplish the TAVI . The advantages of
achieving the implantation in a totally percutaneous way include the use of local anaesthesia with the awake
and collaborating patient as well as a rapid mobilization of the patient and a reduction in hospitalization
time [14,15] . Closing tools and techniques seem to have favourable outcomes and have been increasingly used;
however due to the large caliber of the sheaths, vigilant closure is necessary to be effective [14,15] . After remov-
ing the sheath, the suture threads with the guidance of additional devices such as ProGlide or ProStar as a
“pre-closure” technique are definitely bound. In details, with the ProGlide system the femoral artery is punc-
tured and dilated with a standard arterial sheath. Then, the ProGlide device is advanced over the guidewire,
and the first suture is deployed slightly angulated at the 10 o’clock position. Guidewire access is maintained,
[16]
and a second ProGlide device is inserted and deployed at the 2 o’clock position . Instead, the ProStar de-
vice is advanced over the guidewire until the dedicated marker lumen shows blood marking, indicating that
the sutures and needles are within the vessel lumen. The needles are pulled back while maintaining the posi-
tion and entry angle of the ProStar device. The device is retracted, and the guidewire is reinserted through
[17]
its gate. Then the device is removed, and a dilator is inserted . At this point, similarly for both the systems,
a regular J wire can be exchanged for a stiffer wire, and the large sheath is advanced under fluoroscopy. Af-
ter conclusion of the procedure the introducer sheath is removed, the guidewire is left in position and then
slowly withdrawn until haemostasis is achieved since it represents the possibility to access to the artery in
the event of bleeding due to the lack of effectiveness of the closure [16,17] . If successful, the suture knot is well
tight and consolidated. Both the ProStar and ProGlide devices require experience and a check angiography
is usually performed by contralateral access and it verifies the absence of injuries in the iliac and femoral
vascular structures. The closure of all percutaneous endovascular access is related to a lower incidence of late
groin complications and a diminished procedural time [14,15] .

Percutaneous vs. surgical cut-down in TF TAVI
Earlier studies concerning percutaneous endovascular repair of aortic aneurysm indicated comparable
feasibility and safety of the complete percutaneous femoral approach compared to surgical cut-down and
[18]
repair . More recently, several studies have reported complete percutaneous access and closure using the
cross-over technique on the access for device deployment in TF TAVI. They suggest comparable expediency
and security of this novel technique as a potential alternative to the surgical approach on arterial access of
[19]
TF TAVI . Compared to the surgical approach, the complete percutaneous approach using pre-closure
technique for arterial access/closure of large caliber sheaths (22 Fr or 24 Fr) for TAVI is suitable with accept-
able safety and potential clinical benefit including reduction in wound infection, lowering bleeding compli-
[19]
cation, and reduced hospital stay while maintaining similar major vascular event rate . Nevertheless, the
incidence of access site vascular events is still higher in the complete percutaneous group even though this
did not appear to affect in-hospital mortality or length of hospital stay if it is recognized in timely manner
and appropriately managed [19,20] .