Percutaneous Management of Vascular Injury after Transfemoral Aortic Valve Implantation

Objectives: Transcatheter aortic valve implantation (TAVI) is an established therapeutic option for patients with severe aortic stenosis and elevated risk for surgery. Transfemoral (TF) access is the most commonly used route for TAVI implantation. Vascular injury continues to be one of the most frequent complications of this procedure. One alternative to open surgical repair is an interventional approach with a percutaneous transluminal angioplasty (PTA) or stent implantation. In this study, we aim to evaluate the percutaneous management of vascular injury after TF TAVI.

Methods: A total of 842 consecutive patients underwent TF TAVI at our institution from January 2015 to December 2017. Types of transcatheter heart valves (THV) used were: Symetis Accurate, 29.6%, n = 249, BostonScientific Lotus 13.9%, n = 117, St. Jude Portico, 13.7%, n = 116, and Edwards SapienXT/3 42.8%, n = 360. All patients received computed tomography for evaluation of relevant anatomical structures including access vessels. Arterial wall calcification and lumen diameters were measured using 3mensio software. Arterial wall calcification was graded according to a three-level scale (mild, moderate, and severe). A 30-day follow-up was available for 95% of patients.

Results: The patient population (male gender 54.8% (n = 462), age 81.8 ± 6.3 years) was treated via right (90.1%, n = 758) or left (9.9%, n = 84) common femoral artery. In 66.6% (n = 561), the use of preclosure systems resulted in immediate adequate hemostasis, whereas in the remaining 33.4% (n = 281), residual bleeding necessitated additional treatment. In 25.6% (n = 216), internal vessel blocking using standard PTA balloons with an inflation time of 3 to 5 minutes. In 5.1% (n = 43), stent implantation for vascular repair was necessary. Most frequently (93%, n = 40), a covered Advanta (Maquet Holding, Germany) stent was used. The remaining three (7%) patients were treated with a Palmaz Genesis stent (Cordis, Switzerland). Most frequent sizes used were 8 × 38 mm in 25.5% (n = 12) and 10 × 38 mm in 21.2% (n = 10). Mean number of stents used per patient was 1.1. In 2.6% (n = 22), surgical vascular repair became necessary. At 30-day follow-up, no patient treated receiving vascular stents required repeat intervention or experienced clinical adverse events.

Conclusion: Management of vascular injury intravascular balloon compression or stent implantation yielded excellent acute results and has become our default approach. Analysis of the mid-term fate of these patients is currently underway.