There is a paucity of data regarding the trends and comparative outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among patients with polyvascular disease (PVD).

The Nationwide Readmissions Database (2016-2020) was queried for patients undergoing AVR. Propensity score matching was used to compare the outcomes of TAVR versus SAVR among patients with PVD, and for comparing TAVR among those with versus without PVD. The primary outcome was in-hospital mortality.

The final cohort included 545,409 hospitalizations for AVR. During the study years, there was an increase in the utilization of TAVR versus SAVR among patients with PVD. Patients with PVD undergoing TAVR were older and more likely to be women compared with patients with PVD undergoing SAVR. Compared with SAVR, patients with PVD undergoing TAVR had lower odds of in-hospital mortality (adjusted odds ratio (aOR) 0.26; 95% confidence interval (CI) 0.19-0.35), acute myocardial infarction (AMI), ischemic stroke, hemorrhagic stroke, and major bleeding, but higher odds of pacemaker and non-elective 90-day readmissions (aOR 1.13; 95% CI 1.01-1.26). TAVR among patients with versus without PVD showed similar in-hospital mortality (aOR 1.10; 95% CI 0.94-1.20), while there were higher odds of AMI, ischemic stroke, and vascular complications after TAVR in patients with PVD. A higher burden of atherosclerotic vascular beds conferred higher mortality with SAVR more than with TAVR, while a higher burden of atherosclerotic vascular beds conferred a higher risk of ischemic stroke and readmissions after both TAVR and SAVR.

Nationwide data demonstrated that patients with PVD who undergo TAVR were associated with lower in-hospital mortality and major cardiovascular complications compared with those who undergo SAVR. Patients with PVD have similar mortality to those with no PVD undergoing TAVR, but were associated with a higher risk for complications and readmission.

Transcatheter aortic valve replacement (TAVR) can be performed through multiple access sites with the preferred approach being transfemoral. In patients with severe peripheral arterial disease and previous grafts, the safety of transfemoral access via direct graft puncture, especially when performed twice within a short period, remains unclear compared to alternative access methods. We present a case demonstrating the safety and efficacy of direct graft puncture for transfemoral access during balloon aortic valvuloplasty (BAV) and TAVR.

An 82-year-old man presented with dyspnea on exertion. Echocardiogram was significant for severe aortic stenosis. Following a heart team discussion, the patient was scheduled for a balloon valvuloplasty followed by staged TAVR. Based on pre-TAVR computed tomography angiogram, the aortobifemoral graft was deemed as an appropriate access site. Micropuncture needle was used to access the right femoral artery graft, and the sheath was upscaled to 10 Fr. He underwent successful intervention to ostial left anterior descending and left circumflex arteries, and BAV with 22 mm Vida BAV balloon. Hemostasis was achieved using Perclose. For TAVR, an 8 Fr sheath was inserted via the right femoral bypass graft. The arteriotomy was pre-closed with two Perclose ProGlides and access was upsized to 18F Gore DrySeal. A 5Fr sheath was used for left femoral bypass graft access. Patient underwent successful TAVR with 29 mm CoreValve. Hemostasis was successfully achieved using 2 Perclose for right access site and one Perclose for left side with no postoperative bleeding complications.

BAV and TAVR are feasible and safe through a direct puncture of the aortofemoral bypass graft with successful hemostasis using Perclose.

Alternative access approaches are required for transcatheter aortic valve replacement (TAVR) cases wherein the transfemoral approach is restrictive with severe calcification. We aimed to examine the safety of the external iliac artery (EIA) as an alternative access site by evaluating the calcification distributions from the common iliac artery (CIA) to the common femoral arteries (CFA).

We retrospectively enrolled 402 patients who underwent TAVR. Using computed tomography, calcification was visually assessed based on the maximal circumferential involvement, length, and morphology, and its volumes were quantitatively measured using a minimum threshold of 600 Hounsfield units in 804 arteries.

The calcification volumes were 0.301 (interquartile range, 0.114-0.624) cc in the CIA, 0.0 (0.0-0.041) cc in the EIA, and 0.047 (0.002-0.158) cc in the CFA (p < 0.01). Maximum calcification of >50% of the arterial circumference was observed in only 7.3% of the EIA, compared to 35.2% and 10.8% of the CIA and CFA, respectively. Almost 55% of the EIA had no calcification, compared with only <5% and 22.7% of the CIA and CFA, respectively. In a subgroup analysis of patients on dialysis, the calcification volume was smallest in the EIA at 0.011 (0.0-0.127) cc (p < 0.01). In all, 33.3% of EIAs had no calcification, while 2.0% of CIAs and 19.6% of CFAs were calcification-free.

Calcification rarely presents qualitatively and quantitatively in the EIA, suggesting that it could be an option for TAVR when the transfemoral access is unsuitable.

We qualitatively and quantitatively evaluated the distribution of calcification in the iliofemoral arteries of patients who underwent TAVR. The calcification was more rarely present in the EIA than in the CIA or CFA.

The online version contains supplementary material available at 10.1007/s12055-024-01841-3.

Transcatheter aortic valve replacement (TAVR), endovascular aortic repair (EVAR), and thoracic endovascular aortic repair (TEVAR) are standard and prolific procedures in the modern cardiovascular world, and appropriate delivery of these endoprostheses requires adequate understanding of the requisite large bore access. Percutaneous large bore access is the preferred route but may be accompanied by complications like thrombosis, hemorrhage, or inability to deliver the device. Anatomic limitations such as vessel tortuosity, small size, and heavy calcification may require alternative approaches for successful large bore access. This study aimed to better define large bore access, as well as to elucidate optimal adjuncts and alternatives to enable successful delivery of large bore endoprostheses.

A systematic review for "large bore access" in the cardiovascular literature was conducted on PubMed and the Cochrane Library Central according to PRISMA guidelines. Identified articles were filtered and sub-selected for TAVR, EVAR, and TEVAR; studies related to other large bore interventions were excluded.

A representative selection of 39 full-text studies included both cardiac and vascular studies and was critically interpreted to identify a consensus definition for large bore access, challenging anatomy, and adjuncts or alternative approaches to the standard transfemoral approach.

Transfemoral access remains the first-line approach but in the setting of unfavorable anatomy, adjunct maneuvers (e.g. intravascular lithotripsy, endoconduits) or alternative approaches (supra-aortic, transcaval) help decrease morbidity, mortality, length of procedure, and overall health care cost in large bore access.

Transaxillary access is the most popular alternative to transfemoral transcatheter aortic valve replacement. Although left transaxillary access is generally preferred, right transaxillary transcatheter aortic valve replacement could be challenging because of the opposing axillary artery and aortic curvatures, which may warrant procedural modifications to improve alignment. Our aim is to compare our single center's outcomes for left and right transaxillary access groups and to evaluate procedural modifications for facilitating right transaxillary transcatheter aortic valve replacement.

Patient characteristics and outcomes were compared for consecutive left or right axillary TAVRs performed from 6/2016 to 6/2022 with SAPIEN 3. The effects of our previously reported "flip-n-flex" technique on procedural efficiency and new conduction disturbances were subanalyzed in the right axillary group.

Right and left transaxillary transcatheter aortic valve replacement were performed in 25 (18 with the "flip-n-flex" technique) and 26 patients, respectively. There were no significant differences between patient characteristics or outcomes. Right axillary subanalysis showed the "flip-n-flex" technique group had significantly shorter fluoroscopy times (21.2 ± 6.2 vs 29.6 ± 12.4 min, p = 0.03) and a trend towards less permanent pacemaker implantation (6.3% vs. 42.9%, p = 0.07) compared to the group without "flip-n-flex".

In our study, despite anatomical challenges, right transaxillary transcatheter aortic valve replacement is comparable to left access. The "flip-n-flex" technique advances right transaxillary as an appealing access for patients with few options.

For the past 20 years, transcatheter aortic valve replacement (TAVR) has been the treatment of choice for symptomatic aortic stenosis. The transfemoral (TF) access is considered the gold standard approach for TAVR. However, TF-TAVR cannot be performed in some patients; thus, alternative accesses are required. Our review paper generalises the TAVR accesses currently available, including the transapical, transaortic, trans-subclavian/axillary, transcarotid, transcaval, and suprasternal approaches. Their advantages and disadvantages have been analysed. Since there is no standard recommendation for an alternative approach, access selection depends on the expertise of the local cardiac team, patient characteristics, and access properties. Each TAVR centre is recommended to master a minimum of one non-TF access alternative. Of note, more evidence is required to delve into the clinical outcomes of each approach, at both early and long-term (Figure 1).

There is a growing body of literature on long-term outcomes post-transcatheter aortic valve replacement (TAVR), but to our knowledge, few research have focused on patients with advanced cardiac dysfunction. This challenging category of patients was excluded from the Partner 3 clinical trial. There are no data to guide the choice of valve type in patients with severely depressed ejection fraction. This study evaluates the safety, efficacy, and outcomes of TAVR in patients with severe aortic stenosis and left ventricular ejection fraction (LVEF) ≤ 35%. It compares post-TAVR survival outcomes with self-expanding (SEV) versus balloon-expandable (BEV) valves in the context of cardiac dysfunction.

A retrospective cohort was conducted on 977 patients who underwent TAVR at Toulouse University Hospital between January 2016 and December 2020. The study population included two groups: LVEF ≤ 35% (N = 157) and LVEF ≥ 50% (N = 820). The group of LVEF ≤ 35% was divided into two subgroups according to the type of implanted device: self-expanding (N = 66) versus balloon-expandable (N = 91). The living status of each of study's participants was observed in December 2022. Patients with low ejection fraction were younger (82 vs. 84.6 years) and commonly males (71.3% vs. 45.6%). Procedural success was almost 98% in both study groups (97.5% vs. 97.9%). The prevalence of all in-hospital post-TAVR complications [acute kidney injury (3.8% vs. 2.2%), major bleeding events (2.5% vs. 3.2%), stroke (1.3% vs. 1.6%), pacemaker implantation (10.2% vs. 10.7%), major vascular complication (4.5% vs. 4.5%), new onset atrial fibrillation (3.2% vs. 3.4%), and in-hospital death (3.2% vs. 2.8%)] were similar between groups (LVEF ≤ 35% vs. LVEF ≥ 50%). No difference in long-term survival has been revealed over 3.4 years (P = 0.268). In patients with LVEF ≤ 35%, except for post-TAVR mean aortic gradient (7.8 ± 4.2 vs. 10.2 ± 3.6), baseline and procedural characteristics were comparable between SEV versus BEV subgroups. An early improvement in LVEF (from 29.2 ± 5.5 to 37.4 ± 10.8) was observed. In patients with LVEF ≤ 35%, the all-cause mortality rate was significantly higher in BEV than that in SEV subgroups, respectively (40.7% vs. 22.7%, P = 0.018). Kaplan-Meier curve showed better survival outcomes after SEV implantation (P = 0.032). A Cox regression identified BEV as independent predictor of mortality [HR = 3.276, 95% CI (1.520-7.060), P = 0.002].

In the setting of low LVEF, TAVR remains a safe and effective procedure not associated with an increased risk of complications and mortality. SEV implantation may likely result in superior survival outcomes in patients with advanced cardiac dysfunction.

Vascular complications after percutaneous transfemoral transcatheter aortic valve implantation (TAVI) are associated with adverse clinical outcomes and remain a significant challenge.

The purpose of this review is to synthesize the existing evidence regarding the iliofemoral artery features predictive of vascular complications after TAVI on pre-procedural contrast-enhanced multidetector computed tomography (MDCT).

A systematic search was performed in Embase and Medline (Pubmed) databases. Studies of patients undergoing transfemoral TAVI with MDCT were included. Studies with only valve-in-valve TAVI, planned surgical intervention and those using fluoroscopic assessment were excluded. Data on study cohort, procedural characteristics and significant predictors of vascular complications were extracted.

We identified 23 original studies involving 8697 patients who underwent TAVI between 2006 and 2020. Of all patients, 8514 (97.9%) underwent percutaneous transfemoral-TAVI, of which 8068 (94.8%) had contrast-enhanced MDCT. The incidence of major vascular complications was 6.7 ± 4.1% and minor vascular complications 26.1 ± 7.8%. Significant independent predictors of major and minor complications related to vessel dimensions were common femoral artery depth (>54 mm), sheath-to-iliofemoral artery diameter ratio (>0.91-1.19), sheath-to-femoral artery diameter ratio (>1.03-1.45) and sheath-to-femoral artery area ratio (>1.35). Substantial iliofemoral vessel tortuosity predicted 2-5-fold higher vascular risk. Significant iliofemoral calcification predicted 2-5-fold higher risk. The iliac morphology score was the only hybrid scoring system with predictive value.

Independent iliofemoral predictors of access-site complications in TAVI were related to vessel size, depth, calcification and tortuosity. These should be considered when planning transfemoral TAVI and in the design of future risk prediction models.