Ipsilateral arterial access for management of vascular complication in transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) requires appropriate vascular access. Access site complications remain an important clinical issue. We report a new access site technique for management of puncture site visualization, reduction in use of contrast dye, in addition to several treatment options for management of vascular complications.

METHODS: Between August 2008 and November 2011, a total of 323 high-risk patients underwent a TAVI procedure at our institution. A new ipsilateral double-puncture technique was used in 189 patients. In case of any vascular complication the distal puncture was intentionally used for retrograde balloon blocking or stent implantation.

RESULTS: Overall mortality at 30 days was 8.7%. The rate of a major vascular complication was 7.1% (standard group 6.7% vs. double access group 7.4%, P = 0.59), resulting in death within 30 days in the standard group in 55.6% as compared to 21.4% in the double access group (P = 0.10), respectively. There was a numerical lower rate of surgical repair within the double access group as compared with the standard group (3.7% vs. 2.1%, P = 0.38). Occurrence of minor vascular complication was higher in the double access group (7.5% vs. 22.2%, P < 0.05). The use of contrast dye was significant lower with the new approach (200.9 ± 94.7 ml vs. 156.6 ± 79.0 ml, P < 0.05), resulting to a significant reduction of acute kidney injury (13.4% vs. 8.5%, P < 0.05). Occurrence of acute kidney injury was associated with a significantly higher 30-day mortality (20.6% vs. 7.3%, P < 0.05) irrespective of the puncture technique used.

CONCLUSION: There was a significant reduction of acute kidney injury and contrast use with using the double access technique. The rate of minor vascular complication was higher within the double access group. In contrast, major vascular complication and subsequent surgical repair was numerically lower within the double access group. However, 30-day mortality was statistically not different with using the double access technique. Performing a distal puncture to the principal access site serves as a safety net to economize the use of contrast dye and to maintain an open lumen for percutaneous treatment of a vascular complication.