Minimizing Peripheral Vascular Complications in Transvascular Transcatheter Aortic Valve Implantation by Surgical Instead of Percutaneous Access in a Consecutive Series of 350 Patients

Objectives: In-hospital mortality for transcatheter aortic valve implantation (TAVI) is currently dropping from between 5.5 and 7.1% (German national aortic valve registry report) in 2011 to 3.8% in current German quality assurance (QA) data in 2015. Vascular complications (VC) after transvascular TAVI currently occur in ~9% (QA). In the PARTNER trial, vascular complications are an independent risk factor for survival. Therefore patients should benefit from minimizing vascular complications.

Methods: Until now, our institutional policy has been the open surgical vascular access in a consecutive transcatheter heart valve series (Edwards Sapien XT and 3). In-patient legal quality assurance data and patient documentation were reviewed. Demographical data and in-hospital morbidity and mortality were analyzed.

Results: In the years 2014 and 2015, a total of 350 consecutive patients received transvascular TAVI (Edwards Sapien XT or 3). There were 328 survivors (93.7%) with a mean in-hospital observation time of 16.9 ± 12.8 days. Generally, nonsurvivors (n = 22, 6.3%) were treated longer (25.3 ± 23.6 vs. 16.3 ± 11.6, p < 0.001). In all patients, a limited surgical vascular access (femoral, iliac, subclavian) was gained under general anesthesia. Vascular complications were observed in also 22/350 (5 out of them within the non-survivor group). They included ischemia, dissection, false aneurysm or hematoma. Surgical technique included patch enlargement, allograft replacement or other. The ratio of such vascular repair was 5/22 (23%) among non-survivors versus 17/328 (5.2%) survivors. Therefore, vessel complications had a negative impact on survival (p = 0.008, Fisher exact test). Remarkably, the presence of peripheral arterial occlusive disease (PAD) was not associated with adverse outcome [86/328 survivors (26%) vs. 5/22 non-survivors (23%); p = 0.8], nor did patients with PAD require surgical vascular repair more often than others (2.3 vs. 4%).

Conclusion: Surgical instead of percutaneous vascular access might reduce the incidence of VC but requires general anesthesia. In our series, the “surgical” policy might have been responsible for the missing correlation of PAD and VC. Surgical vascular access might play a role in PAD TAVI patients in the future.