Vascular Complications and Bleeding After Transfemoral TAVI

Vascular Complications and Bleeding After Transfemoral TAVI: a Comparison Between Surgical and Percutaneous Approaches

Since the first implantation by Cribier, transcatheter aortic valve implantation (TAVI) revolutionized the management of severe symptomatic aortic stenosis. Indeed, TAVI is indicated as an alternative to conventional surgery in patients at high surgical risk or contra-indicated to conventional surgery.

However, TAVI remains associated with specific complications related to the technics itself dominated by vascular complications and conductive disorders. Major vascular complications remain frequent after TAVI despite improvements in operators' experience, patient's selection and lower profile devices. Indeed, according to the Valve Academic Research Consortium 2 (VARC-2) criteria , major VC are still reported with an incidence of 1.5% to 15% of the procedures in registries and may be associated with unfavorable clinical outcomes. Currently, percutaneous approach (PC) in transfemoral TAVI is performed in routine, considered as a less invasive strategy than the traditional surgical cutdown (SC) performed in the first TAVI experience. Indeed, percutaneous approach may facilitate the local anesthesia and does not require the presence of the surgeon in the catheterization laboratory . However, surgical approach is still performed in many centers, allowing a better control of the puncture site with a low rate of vascular complications . Several non-randomized studies compared the two approaches with contradictory results]. No data are available comparing both approaches performed by the same team during the same period.

The aim of this study was to compare percutaneous and surgical approaches in terms of vascular complications and bleeding in patients undergoing transfemoral TAVI.

Study Overview

• Status: Completed
• Conditions: Severe and Symptomatic Aortic Stenosis; Undergoing TAVI

Detailed Description

This prospective monocentric observational study aims to include all patients undergoing TAVI via transfemoral access from November 2017 at Montpellier University Hospital, France.

All procedures are performed in the same site by 7 medical teams including 4 different surgeons and 9 interventional cardiologists.

All patients have severe symptomatic aortic stenosis secondary to degenerative disease confirmed by transthoracic echocardiography (mean gradient >40 mmHg and/or valve area <1 cm2) and are deemed for TAVI after heart team decision.

Before the procedure, a multislice computerized tomography (MSCT) is systematically performed to evaluate the aortic annulus, the aorta and to determine the access site.

The choice of percutaneous or surgical is at operators' discretion, according to predictable access site difficulties (calcifications, tortuosity femoral bifurcation height) and global considerations as obesity.

Both procedures are performed during the same period, our center using both techniques in a common way.

TAVI procedure are performed under general anesthesia in the majority of cases.

Percutaneous approach The anterior wall of the common femoral artery are punctured under echographic guidance after selection of a site free of calcifications and above the femoral bifurcation and a 6-French sheath was inserted.

Two Perclose ProGlide® devices (Abbott Vascular, Santa Clara, CA) are used to perform the perpendicular preclosing. After the deployment of the prosthesis, the TAVI sheath is removed and the nodes from the two previously placed ProGlide® devices were tightened. Final femoral angiographic control is not systematic.

Surgical approach A surgical equivalent of the " preclose technique ", untitled the " zip technique " is performed routinely in our center. This technique avoids arterial crossclamping and purse string effect. Briefly, the femoral artery is exposed through a transversal groin incision, the anterior wall of the artery is cleaned from surrounding tissues up to a few centi- meters. The most suitable site is chosen free of calcifications allowing a puncture and insertion of a 6-French sheath. At the end of the procedure, both ends of the sutures are gently pulled to obtain coaptation of the arterial wall.

Study endpoints The primary endpoint of our study is a composite of vascular complications and bleeding defined by the modified VARC-2 classification.

Secondary end points included complications after TAVI, amount of contrast, amount of radiation, procedure duration, hospitalization length.

Data assessment Data on patients' baseline characteristics, procedural details and in-hospital outcomes is collected from a prospective TAVI database.

No additional testing or biological samples were specifically required for this study.

• Study Type: Observational
• Enrollment (Actual): 300

Contacts and Locations

Study Locations

• France
  • Montpellier, France, 34295
    • Uhmontpellier

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

November 2017 at Montpellier University Hospital, France, for severe symptomatic aortic stenosis

Description

Inclusion criteria:

• Patients undergoing a TAVI at Montpellier University Hospital
• Since November 2017
• With implantation of a COREVALVE or EDWARDS
• By femoral approach

Exclusion criteria:

• Minor patient
• Patient unable to give consent for reasons of understanding or language barrier

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
vascular complications and bleeding	The primary endpoint of our study is a composite of vascular complications and bleeding defined by the modified VARC-2 classification	1 day (at the end of hospitalization)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Other complications after TAVI	Other complications after TAVI	1 day (at the end of hospitalization)
amount of radiation	amount of radiation	1 day (at the end of hospitalization)
amount of contrast	amount of contrast	1 day (at the end of hospitalization)
procedure duration	procedure duration	1 day (at the end of hospitalization)
hospitalization length	hospitalization length	1 day (at the end of hospitalization)

Collaborators and Investigators

• Sponsor: University Hospital, Montpellier
• Investigators: Principal Investigator: Florence LECLERCQ, University Hospital, Montpellier

Study record dates

Study Major Dates

• Study Start (ACTUAL): February 1, 2019
• Primary Completion (ACTUAL): December 31, 2019
• Study Completion (ACTUAL): December 31, 2019

Study Registration Dates

• First Submitted: March 5, 2019
• First Submitted That Met QC Criteria: March 5, 2019
• First Posted (ACTUAL): March 6, 2019

Study Record Updates

• Last Update Posted (ACTUAL): March 10, 2020
• Last Update Submitted That Met QC Criteria: March 9, 2020
• Last Verified: March 1, 2020

More Information

Terms related to this study

• Keywords: TAVI; preclosing
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Aortic Valve Disease; Heart Valve Diseases; Ventricular Outflow Obstruction; Aortic Valve Stenosis
• Other Study ID Numbers: RECHMPL18_0486

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: NC

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No