Totally Percutaneous Transfemoral Transcatheter Aortic Valve Replacement Despite Failure to Deploy a Vascular Closure Device: A Feasibility Report

Background. Transcatheter aortic valve replacement (TAVR) is preferably performed as a completely percutaneous procedure via transfemoral access. Suture-mediated vascular closure devices are deployed prior to sheath insertion (pre-closure). Inability to perform pre-closure may lead to abortion of the procedure, surgical femoral artery cutdown or selection of more invasive alternative access. Patients who are considered at high-risk for complications of surgical vascular repair may benefit from an alternative method for performing a totally percutaneous transfemoral TAVR procedure. We studied a strategy of planned stent graft implantation for achieving access site hemostasis following valve implantation in patients undergoing transfemoral TAVR in whom pre-closure failed.
Methods. We analyzed a prospective institutional TAVR registry and identified a cohort of patients who were selected for transfemoral TAVR, in whom pre-closure failed. In these patients a strategy of planned stent graft implantation within the femoral artery was used.
Results. Planned stent graft implantation was used for achieving access site hemostasis in 11 patients in whom pre-closure failed (1.5% of 744 patients undergoing transfemoral TAVR). These patients were considered at high-risk for complications of vascular surgery due to advanced age, frailty, co-morbidities, or immobility. Stent graft implantation achieved access site hemostasis in all patients. During follow-up, 30-day mortality was zero, 1-year mortality was 27% and none of the patients required additional vascular interventions.
Conclusion. Our preliminary data suggests that planned stent graft implantation within the femoral artery may achieve access site hemostasis and enable a totally percutaneous TAVR procedure despite failure to perform pre-closure.