Parker Michael H, Mukherjee Dipankar, Ryan Liam
Department of Surgery, General Surgery, Inova Fairfax, Fairfax, VA, USA.
Department of Surgery, Vascular Surgery, Inova Fairfax, Fairfax, VA, USA.
Vascular. 2021 Aug;29(4):610-615. doi: 10.1177/1708538120969468. Epub 2020 Nov 4.
Trans-catheter aortic valve replacement is a commonplace procedure for patients with aortic valvular stenosis who are at a high risk for surgery, evidenced by the 34,892 trans-catheter aortic valve replacements performed in 2016. Trans-catheter aortic valve replacement's rate of major vascular complications with second-generation closure devices is 4.5% according to a meta-analysis of 10,822 patients. To manage those complications, percutaneous approaches to arterial repairs show shorter length of stay, higher rate of direct to home discharge and equivalent outcomes at long-term follow-up. This study's goal is to show that one center's vascular access strategy can decrease open repairs and improve patient outcomes.
Our team began accessing the mid-common femoral artery at least 1-2 cm proximal to the takeoff of the profunda femoris. This allowed an endovascular stent to be deployed if necessary via contralateral femoral access. We performed a completion angiogram following every trans-catheter aortic valve replacement to ensure no arterial complications. We conducted a retrospective review of a prospectively maintained database for all trans-catheter aortic valve replacement cases at a tertiary care center from 1 January 2016 to 30 June 2018.
A total of 699 trans-catheter aortic valve replacement procedures were performed with 25/31 (80.6%) cases met inclusion criteria. An increase was noted in the number of stent procedures versus cutdown procedures over time ( < 0.001). A decrease was noted in the number of vascular surgery team activations following trans-catheter aortic valve replacement ( = 0.004). A non-significant trend was noted toward a shorter median length of stay for the stent group ( = 0.149). There was no increase in 30-day mortality rate (0.0% for both groups) or 30-day readmissions (4/15 (26.7%) for stents vs. 2/10 (20.0%) for open repairs; > 0.999).
This strategy is safe and feasible to implement and reduces the number of open repairs following trans-catheter aortic valve replacement, activation of surgical resources, and possibly the length of stay.
