RS11 - The Role of the Vascular Surgeon in Transcatheter Aortic Valve Implantation

Objectives: Transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic valve stenosis among patients at high/intermediate operative risk. Percutaneous transfemoral access (TF) is the preferred route due its low invasiveness and lower perioperative morbidity/mortality compared with the trans-apical/axillary/aortic approach. On the other hand, vascular access complications (VACs), occurring from the TF-access, are associated with prolonged hospitalization and 30-day mortality. In addition, the presence of severe peripheral artery diseases as well as aortic aneurysm or cerebrovascular insufficiency may need concomitant endovascular management. A multidisciplinary team with Interventional Cardiologists and Vascular Surgeons may minimize the rate of VACs in patients with challenging femoral/iliac access and significant disease of other vascular districts, thus optimizing the outcome of TF-TAVI. The aim of the study was to evaluate the role of Vascular Surgeons in TF-TAVI.

Methods: We conducted a retrospective single center review of all TAVI assisted by Vascular Surgeons between 2016 and 2020 in a high-volume tertiary hospital. Pre, intra and postoperative data were clustered and retrospectively analyzed by a dedicated group of both Interventional Cardiologists and Vascular Surgeons. VACs were defined according with the Valve Academic Research Consortium (VARC) 2 guidelines. The outcomes of TAVI procedures with Vascular Surgeons involvement were assessed as the study’s endpoints

Results: Overall, 937 TAVI procedures were performed with a TF approach ranging between 78% (2016) and 98% (2020). Vascular Surgeons were involved in 67(7%) procedures with the following indications: concomitant abdominal aortic aneurysm (EVAR+TAVI) - 3(4%), severe carotid stenosis (TAVI+CAS) - 2(3%), hostile femoral/iliac access or VACs - 62(93%). Balloon angioplasty of iliac artery pre TAVI implantation was performed in 51 cases (conventional PTA:38/51-75%; conventional PTA + intravascular lithotripsy:13/51-25%). TAVI procedure was successfully completed by percutaneous TF approach in all 62 cases with challenging femoral/iliac access. VACs necessitating interventions occurred in 18/937(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%) VACs were treated during the index procedure. There was no case of procedure related mortality or 30-day readmissions

Conclusions: The necessity of Vascular Surgeon assistance in TAVI procedures is not infrequent and allow safe/effective device introduction through challenging femoral/iliac access. Similarly, the concomitant significant disease of other vascular districts can be safely addressed potentially reducing postoperative related mortality/morbidity. The organization of composite cardiological and vascular surgery teams should be encouraged wherever possible