title: Impact of femoral artery puncture using digital subtraction angiography and road mapping on vascular and bleeding complications after transfemoral transcatheter aortic valve implantation.
abstract: OBJECTIVE
  The use of large-diameter sheaths carries the risk of significant vascular and bleeding complications after transfemoral transcatheter aortic valve implantation (TAVI). In this analysis, we sought to assess the impact of a modified femoral artery puncture technique using digital subtraction angiography (DSA) and road mapping during transfemoral TAVI on periprocedural vascular and bleeding events.
  
  
  RESULTS
  This is a retrospective analysis of transfemoral TAVI patients included in a prospective institutional database. The modified femoral artery puncture technique using DSA-derived road mapping guidance was introduced in October 2012. Before the introduction of this technique, vascular puncture was acquired based on an integration of angiographic data, the bony iliofemoral landmarks and a radiopaque object. Consecutive patients who underwent TAVI with the road mapping technique (RM group, n=160) were compared with consecutive patients who underwent TAVI without road mapping (control group, n=160) prior to its introduction. A standardised strategy of periprocedural anticoagulation was adopted in both groups as well as the use of a single suture-based closure device. All endpoints were defined according to the VARC-2 criteria for event definition. The mean age in the RM group was 80±7.7 years compared to 81±5.9 years in the control group (p=0.19), and females were equally distributed between both groups (63.1% vs. 58.1%, p=0.36). The baseline logistic EuroSCORE was 20.7±14.4% vs. 24.9±15.2% in the RM and control group, respectively (p=0.01). Notably, sheath size was significantly larger in the RM compared to the control group due to the more frequent use of the 20 Fr sheath (23.8% vs. 1.8%, p<0.001, respectively) associated with the more frequent implantation of the 29 mm Edwards SAPIEN XT valve in the RM group (43.8% vs. 7%, respectively, p<0.001). Despite the latter finding, both major vascular complications and major bleeding at 30 days were significantly lower in the RM group compared to the control group (4.3% vs. 11.8%, p=0.01, and 14.4% vs. 25.6%, p=0.01). An analysis limited to access site-related complications also revealed lower events in the road map group but did not reach statistical significance (8.1% vs. 13.8%, p=0.1). Other forms of vascular and bleeding complications as well as all-cause mortality were comparable in both groups.
  
  
  CONCLUSIONS
  A modified femoral artery puncture technique using DSA and road mapping was associated with a reduction in major vascular and bleeding complications after transfemoral TAVI, and provides a simple and effective strategy for potentially improving patient outcomes.
authors.affiliation: Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Bad Segeberg, Germany.
authors.forename: Mohamed
authors.initials: M
authors.lastname: El-Mawardy
authors.forename: Bettina
authors.initials: B
authors.lastname: Schwarz
authors.forename: Martin
authors.initials: M
authors.lastname: Landt
authors.forename: Dmitriy
authors.initials: D
authors.lastname: Sulimov
authors.forename: Julia
authors.initials: J
authors.lastname: Kebernik
authors.forename: Abdelhakim
authors.initials: A
authors.lastname: Allali
authors.forename: Bjoern
authors.initials: B
authors.lastname: Becker
authors.forename: Ralph
authors.initials: R
authors.lastname: Toelg
authors.forename: Gert
authors.initials: G
authors.lastname: Richardt
authors.forename: Mohamed
authors.initials: M
authors.lastname: Abdel-Wahab
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction / Q000009:adverse effects / Q000379:methods; D001024:Aortic Valve Stenosis / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods; D005260:Female; D005263:Femoral Artery; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome