Vascular surgeons ‘have a role to play’ in transcatheter aortic valve replacement procedures

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Enrico Gallitto

Vascular surgery assistance in transcatheter aortic valve replacement (TAVR) can facilitate safe and effective device introduction through cases involving challenging femoral or iliac access.

This was the conclusion delivered by Enrico Gallitto, MD, from the University of Bologna, Bologna, Italy, during the 2022 Vascular Annual Meeting in Boston in a presentation looking at the role of the vascular surgeon in transcatheter aortic valve implantation.

During Thursday’s Plenary Session 3, Gallitto delivered the findings of an analysis of TAVR procedures assisted by vascular surgeons between 2016 and 2020—in what Gallitto describes as a “high-volume tertiary hospital.”

Gallitto noted that TAVR has become the standard treatment for severe aortic valve stenosis among patients at both high and intermediate operative risk for surgical valve replacement. Percutaneous transfemoral access is the preferred route for the procedure, he added, due to its low invasiveness and lower perioperative morbidity and mortality compared to transapical, transaxillary or transaortic approaches.

However, Gallitto added that vascular access complications occurring from the transfemoral access are associated with prolonged hospitalization and 30-day mortality, and the presence of severe peripheral arterial diseases as well as aortic aneurysm or cerebrovascular insufficiency may necessitate concomitant endovascular management.

“A multidisciplinary team with interventional cardiologists and vascular surgeons may minimize the rate of vascular access complications in patients with challenging femoral/ iliac access and significant disease of other vascular districts,” he added, noting that this may be important to optimize the outcome of transfemoral TAVR.

The study sought to evaluate the role of vascular surgeons in transfemoral TAVR.

Gallitto and colleagues looked at pre-, intra- and postoperative data for the given time period, which were clustered and retrospectively analyzed by a dedicated group of both interventional cardiologists and vascular surgeons.

Vascular access complications were defined according with the Valve Academic Research Consortium (VARC) 2 guidelines, and the outcomes of TAVR procedures with vascular surgeon involvement were assessed as the study’s endpoints. Overall, Gallitto and colleagues assessed a total of 937 TAVR procedures performed with a transfemoral approach ranging between 78% (2016) and 98% (2020).

Vascular surgeons were involved in 67 (7%) procedures. Of these, three (4%) had indications for concomitant abdominal aortic aneurysm (endovascular aneurysm repair [EVAR]+TAVR), two (3%) with severe carotid stenosis (TAVR+CAS), and 62 (93%) had hostile femoral or iliac access or vascular access complications.

Balloon angioplasty of iliac artery pre-TAVR was performed in 51 cases (conventional percutaneous transluminal angioplasty [PTA]: 38/51‒75%; conventional PTA+intravascular lithotripsy [IVL]: 13/51–25%).

The TAVR procedure was successfully completed via the percutaneous transfemoral approach in all 62 cases with challenging femoral/iliac access, Gallitto reported.

Vascular access complications necessitating interventions occurred in 18 out of the 937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively.

They were managed by surgical or endovascular maneuvers in 3/18 (83%) and 15/18 (25%) cases, respectively. Fifteen/18 (83%) vascular access complications were treated during the index procedure, Gallitto reported, adding that there were no instances of procedure-related mortality or 30-day readmissions.

In his concluding remarks, Gallitto commented that the necessity of vascular surgeon assistance in TAVR procedures is “not infrequent,” and participation by vascular specialists allows safe and effective device introduction through challenging femoral/iliac access, for example.

“Similarly, the concomitant significant disease of other vascular districts can be safely addressed potentially reducing postoperative related mortality/morbidity,” he noted. “The organization of composite cardiological and vascular surgery teams should be encouraged wherever possible.”

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