Original title: Factors associated with vascular complications in patients undergoing balloon-expandable transfemoral transcatheter aortic valve replacement via open versus percutaneous approaches. Reference: Kadakia MB et al. Circ Cardiovasc Interv. 2014; Epub ahead of print.

This retrospective study included 331 patients undergoing transfemoral TAVR in one center between 2007 and 2013. 64% of the population were treated with the fully percutaneous approach and the rest via the open surgical approach. Only the Edwards valve was employed (Sapien o Sapien XT).

At baseline, patients in the open surgical group presented major heart disease, previous infarction, chronic renal failure, worse functional class and higher STS score (11.1 vs 9.1; p=0.007). Those treated with fully percutaneous approach presented shorter length of stay (7.7 vs 9.9 days; p=0.003) and fewer vascular complications at 30 days (11% vs 20%: p=0.03).

The most common complications in both groups were iliofemoral perforation and iliofemoral dissection. There was no difference in all-cause in-hospital mortality between the groups.

After propensity score matching, on account of the different baseline characteristics, each group had 112 patients. The difference in major vascular complications disappeared (13% vs 15%; p=0.7) but the advantage of the fully percutaneous approach as regards hospital stay length remained (7.9 ± 5.5 days vs 10.0 ± 10.1; p=0.04).

The multivariable analysis showed 2 predictors of overall vascular complications: female sex (OR 2.2; IC 95% 1.1 a 4.3) and sheath oversizing (per 1 mm increase in the difference between sheath outer diameter and minimal artery diameter; OR 1.4; IC 95% 1.1 to 1.8).

Conclusion

Fully percutaneous TAVR was associated with a similar vascular complications risk and a significant shorter hospital stay compared to open surgical TAVR. Sheath oversizing (with respect to artery diameter), and female sex were associated to vascular complications, despite the approach.

Editorial Comment

Technological advances will continue to reduce sheath size, which in turn will reduce vascular complications. However, in the individual patient, outcomes will depend on careful planning, since sheath oversizing is the strongest predictor of vascular complications. 

A shorter hospital stay and a similar vascular complications rate makes the percutaneous approach the ideal technique; however, closure device cost vs. hospital cost should always be pondered on account of the different contexts in different countries. 

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