Vascular complications in patients undergoing percutaneous transfemoral aortic valve implantations

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of severe aortic stenosis. Transfemoral TAVI has become the most common approach among the various access routes due to its less invasive nature. Nonetheless, the ‘big five’ complications after TAVI remain a significant concern: conduction abnormalities with the necessity for permanent pacemaker implantation, paravalvular leakage, disabling stroke, acute kidney injury and vascular and bleeding complications [1]. Due to the findings of Piperata et al. [2] that even minor vascular complications have an impact on early and long-term outcomes, we would like to address the main points on vascular access management in TAVI procedures. The Valve Academic Research Consortium (VARC) criteria have been widely adopted to standardize definitions and reporting of TAVI-related complications, including access site vascular complications associated with increased mortality rates, prolonged hospitalization, and higher healthcare costs [3]. Therefore, understanding these complications and employing effective preventive measures is crucial for improving patient safety and TAVI success rates.

First, preoperative imaging plays a crucial role in identifying suitable access sites and evaluating the vascular anatomy for TAVI. Computed tomography angiography is commonly used to evaluate valve specifications and detailed information about the vessels to enable procedural planning.

Ultrasound-guided puncture has emerged as a promising technique to reduce the risk of access site complications during TAVI. Real-time visualization of the femoral artery allows for precise needle placement and minimizes the chance of perforation or accidental damage. Studies have demonstrated that ultrasound-guided puncture is associated with a lower incidence of vascular complications and improved procedural success rates, making it an essential tool for enhancing patient safety during the procedure [4].

Moreover, achieving hemostasis and secure closure of the arterial access site is critical to preventing vascular complications post-TAVI. Initially, the surgical approach to the femoral artery was the standard approach, while percutaneous closure devices have been established as suture-based devices or plug-based anchors. Several studies have shown similar safety and efficacy of these devices but in sub-group analyses higher incidence of vascular and bleeding complications in plug-based vascular closure devices (VCD) [5]. Nowadays, we also highlight that the surgical access route should also be considered in the case of peripheral artery disease [6].

Managing vascular complications in patients undergoing percutaneous transfemoral TAVI requires a multidisciplinary approach involving both interventionalists and surgeons. Angiographic control at the end of the procedure, prompt recognition and collaboration between these specialists are crucial in effectively addressing access site bleeding, pseudoaneurysms, and arterio-venous fistulae. A well-coordinated team effort ensures timely interventions, improving patient outcomes and reducing morbidity associated with these complications.

In conclusion, access site vascular complications remain a notable concern in patients undergoing percutaneous transfemoral TAVI. Adherence to Valve Academic Research Consortium criteria, preoperative imaging, and using ultrasound-guided puncture can help reduce the incidence of these complications and improve patient outcomes. The appropriate closure device or surgical access route should be selected based on the individual patient and institutional considerations. As TAVI technology evolves, ongoing research and improved procedural techniques planned, performed, and managed by an interdisciplinary team will further reduce complications, leading to better patient care and outcomes in this ever-evolving field.

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