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Page 4 of 11 Depboylu et al. Vessel Plus 2018;2:26 I http://dx.doi.org/10.20517/2574-1209.2018.39

Major Vascular Complications
All other vascular injuries, those cause tissue malperfusion, require blood transfusion over 4 units or surgery.

Heart team has the key role in preventing and/or overcoming major vascular complications. Not only the
status of aortic valve and device landing zone, a full evaluation including the status of the access-site, access
artery diameter, its stenosis and/or calcification, sharp angulations and/or tortuosity of the conducting arter-
ies, should be done by using computerized tomography and catheter angiography.

Vascular access-site/device landing zone complications
Vascular Access-Site Complications
Vascular access-site complications are mainly caused by the mismatch of access artery and sheaths of deliv-
ery system. Sex (female), calcification status of the access artery, ratio of the sheath to access artery diameter (>
[4]
1.05) and the experience of the operator were determined as major predictors of vascular access-site com-
[5,6]
plications . With the improvements in the delivery systems (decreased diameters), improvements in the
pre-procedural patient evaluation and increased surgical experience, the vascular access-site complications
[7]
decreased nowadays . Despite all the improvements, if the conducting arteries have sharp angulations, tor-
tuosity or untreated aneurysms, and the conducting artery lumen is narrower than 6 mm with calcifications,
the trans-femoral, trans-subclavian and trans-carotid accesses are not recommended, instead, trans-apical
or direct-aortic accesses should be used.

In case of any complication, angiographic evaluation of the artery may be the urgent diagnosis method and
an acute hypotension without other causes may also support the diagnosis of major arterial injury. Urgent
endovascular or surgical repair is recommended for treatment.

Device landing zone complications
Rupture of the device landing-zone is a rarely encountered complication (1%), but has a high mortality risk
[8,9]
(48%-50%) . The presence of severe annular, sub-annular, left ventricular outflow tract calcifications and
[10]
valve over sizing were determined as the predictors of this complication . From the perspective of tissue
quality, patients older than 90 years, chronic steroid users and immunosuppressed hosts have a higher risk of
annular injury. Device landing-zone complications such as injury, rupture or dissection of aorta, ventricular
septal defect and aorto-ventricular fistula are mostly seen in implantation of balloon-expandable valves or
[11]
in balloon dilatation of a self-expandable valve after implantation . Smaller annular area (< 300 cm ) may
2
[12]
increase the annular rupture due to relative valve oversizing . Also, aggressive oversizing of the prosthesis,
may decrease significant aortic regurgitation but induce conduction disorders requiring pacemaker implan-
[13]
tations .
In case of complication, trans-esophageal echocardiography may give critical information about new peri-
cardial effusion or tamponade, aortic root injury and aortic dissection. The occurrence of an acute hypoten-
sion supports the diagnosis. If the problem is only aortic root hematoma with no rupture, hemodynamic
support with inotropes, reversal of anticoagulation, then transfusion of fresh frozen plasma and close obser-
vation may be enough. Otherwise, if there is rupture, cardiac tamponade occurs frequently and reversal of
[14]
anticoagulation, pericardial drainage or surgical repair are recommended .

AORTIC VALVE REGURGITATION
Aortic valve regurgitation is frequently seen after TAVR and can be evaluated under two subheadings.

Paravalvular leak
The incidence of paravalvular leak is 50%-85%. Whilst most of them are mild, moderate and/or severe leaks
[15]
are seen up to 24% that increase the mortality of the procedure up to 4 times in the first year [16,17] . Occur-