title: A new technique for vascular access management in transcatheter aortic valve implantation.
abstract: OBJECTIVE
  To describe results from a novel percutaneous technique designed to minimize the risk of hemorrhage in the event of a major complication during transcatheter aortic valve implantation.
  
  
  BACKGROUND
  Vascular access management is a major challenge in transfemoral TAVI due to the large introducer sheathes required.
  
  
  METHODS
  Fifty-two pts underwent TAVI between November 2007 and March 2009. Of these, 37 received an Edwards-Sapien Valve (23 mm valve: 17/37; 26 mm valve: 20/37) whilst 15 patients received a CoreValve (26 mm valve: 6/15; 29 mm valve: 9/15). Using a crossover technique, the opposing femoral artery was cannulated with a 7Fr long sheath. This allowed contralateral passage of a balloon and inflation in the proximal iliac. The sheath was then removed and Prostar sutures tied in a dry field. Balloon optimization of the puncture site was performed as required.
  
  
  RESULTS
  In three subjects, elective surgical repair was undertaken due to excessive femoral arterial calcification. In the remaining 49, the crossover technique was employed and closed with two Prostar devices (Edwards-Sapien) or one (CoreValve). There were serious "on-table" complications in seven patients, six due to the large introducer sheathes used in the TAVI procedure-iliac avulsion, two iliac dissections, iliac perforation, common femoral perforation and scrotal hematoma. All were repaired safely by combined surgical and endovascular techniques, using the crossover technique to ensure patient stability. All made a good recovery and were independently ambulant at discharge.
  
  
  CONCLUSIONS
  Using crossover balloon inflation as an adjunct to Prostar closure may be helpful for managing TAVI vascular access sites.
authors.affiliation: San Raffaele Scientific Institute and Columbus Hospitals, Milan, Italy.
authors.forename: Andrew S P
authors.initials: AS
authors.lastname: Sharp
authors.forename: Iassen
authors.initials: I
authors.lastname: Michev
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.forename: Maurizio
authors.initials: M
authors.lastname: Taramasso
authors.forename: Cosmo
authors.initials: C
authors.lastname: Godino
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.forename: Paulo
authors.initials: P
authors.lastname: Denti
authors.forename: Enrica
authors.initials: E
authors.lastname: Dorigo
authors.forename: Andrea
authors.initials: A
authors.lastname: Giacomini
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Iaci
authors.forename: Mario
authors.initials: M
authors.lastname: Manca
authors.forename: Alfonso
authors.initials: A
authors.lastname: Ielasi
authors.forename: Matteo
authors.initials: M
authors.lastname: Montorfano
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve; D021721:Balloon Occlusion / Q000295:instrumentation; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation; D004867:Equipment Design; D005263:Femoral Artery / Q000000981:diagnostic imaging; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000628:therapy*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging; D011474:Prosthesis Design; D011677:Punctures; D015641:Radiography, Interventional; D013536:Suture Techniques; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome