Objectives

Transfemoral (TF) transcatheter aortic valve implantation (TAVI) is traditionally performed with an interventional and a non-interventional access to the iliac vessels to constitute a safety net and facilitate balloon angioplasty or stent implantation in cases in which preclosure devices fail or significant stenosis, dissection or bleeding of the interventional access occurs. However, a minimalistic TF-TAVI approach using a single femoral puncture is increasingly used at our center. We herein report our experience with this procedure.

Methods

Between 02/2020 and 07/2021 63 patients (53.93% female, 82.8± 4.7 years, logEuroSCORE II 12.10 ± 6.5%) received TF- TAVI for severe symptomatic aortic valve stenosis using a minimalistic approach. The procedure consisted of visualization of iliac vessels by a long pigtail catheter, introduced via a right-sided transradial access and subsequent controlled puncture of the femoral artery proximal of the bifurcation as determined in preoperative computed tomography. After transcatheter heart valve (THV) implantation, iliac vessels were closed by using a collagen plug based closure device (MANTA™, Teleflex Medical Inc., Wayne, PA, USA). Data were retrospectively analyzed according to updated Valve Academic Research Consortium (VARC-2) definitions.  

Results

Visualization of iliac vessels by transradial approach and adequate localization of the puncture site was successful in all cases. Implanted THV consisted of Sapien 3 Ultra (18/63), EvolutR (11/63), Acurate neo/neo2 (6/63), Portico (26/63) and Lotus (2/63). Balloon pre- and postdilatation were used in 47/63 (74.6%) and 25/63 (39.68%) of patients, respectively. Procedure time and amount of contrast agent were 52.5±17.2 minutes and 161.6±57.3 ml. Device success and early safety were 95.2% (60/63) and 95.24% (60/63) with resulting transvalvular peak/mean pressure gradients of 14.17±7.58/7.43±4.12 mmHg and PVL ˃mild in 4/63 patients (6.4%). Failure to reach these composite endpoints were due to one conversion to sternotomy, one transvalvular mean pressure gradient ˃ 20 mmHg, one THV dislocation with subsequent implantation of a second valve and 2 cases of acute kidney injury. There were no bleeding complications and one (1/63, 1.6%) access site complication including femoral stent implantation. 30-day mortality was 0.0% (0/63). The VARC-2 adjudicated clinical endpoints disabling stroke and myocardial infarction occurred in 0.0% (0/63) of patients. Postprocedural PPM implantation was necessary in 17.5% (11/63) of patients. Intensive care unit and overall hospital stay were 1.1±0.4 and 6.4±2.1 days, respectively.

Conclusion

Minimalistic TF- TAVI using a single femoral puncture is safe and feasible and has become our default approach. In this single center patient cohort, no bleeding and only one access site complication were seen accompanied by adequate clinical and hemodynamic results. Main advantages of the herein described approach is sparing of a non-interventional puncture site omitting possible complications (bleeding, dissection, stenosis) of the second femoral puncture. Further beneficial aspects may include shorter procedure times, less amount of used contrast agent and faster mobilization, which should be subject of further investigations including larger patient cohorts.