Increased utilization of femoral artery access for transcatheter aortic valve implantation associated with a strategy of stent-graft implantation for treatment of vascular complications

Background: Transfemoral access is the preferred vascular approach for transcatheter aortic valve implantation (TAVI) procedures, however unfavorable ileo-femoral artery anatomy may dictate selection of alternative access sites. Access site bleeding occurs frequently following TAVI and may be treated percutaneously by stent-graft implantation. We studied changes in utilization of transfemoral access following adoption of a strategy of stent-graft implantation for treatment of access site bleeding.

Methods: A prospective institutional TAVI registry was reviewed and patients who underwent stent-graft implantation were identified. Baseline characteristics and procedural data were analyzed, and follow-up was performed.

Results: Between 2010-2019, 661 TAVI procedures were performed. Transfemoral vascular access was used in 643 (97%) cases. Alternative vascular access sites included: subclavian (13), transapical (3) and direct aortic (2). Stent-grafts were implanted in 134 patients (20% of TAVI cohort) and achieved hemostasis in all cases. Indications for stent-graft implantation were failure of initially deployed vascular closure devices (VCD) to achieve hemostasis following valve deployment (124 patients), initial failure to deploy a VCD (8), rupture of the common iliac artery (1) and subclavian artery injury (1). During the study period there was a parallel increase in stent-graft implantation (15% to 24%, p=0.001) and utilization of transfemoral vascular access (94% to 99%, p=0.003).

Conclusions: Stent-graft implantation for treatment of vascular access site bleeding following TAVI achieved hemostasis in all patients, without adverse sequela. Adoption of a strategy of stent-graft implantation was followed by increased utilization of transfemoral access, including cases in which initial VCD deployment failed.