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Vol. 67. Issue 5.
Pages 410-412 (May 2014)
Vol. 67. Issue 5.
Pages 410-412 (May 2014)
Scientific letter
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Usefulness of Placing a Wire From the Contralateral Femoral Artery to Improve the Percutaneous Treatment of Vascular Complications in TAVI
Utilidad de colocar una guía desde la femoral contralateral para facilitar el tratamiento percutáneo de complicaciones vasculares en los TAVI
Eulogio Garcíaa,
Corresponding author

Corresponding author:
, Patricia Martín-Hernándeza, Leire Unzuéb, Rosa Ana Hernández-Antolína, Carlos Almeríaa, Ana Cuadradoc
a Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Madrid, Spain
b Servicio de Cardiología, Hospital Universitario Madrid Montepríncipe, Madrid, Spain
c Servicio de Anestesia, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Table. Description of Patients’ Baseline Characteristics, Complications, Vascular Complications, and Therapeutic Management
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To the Editor,

Transcatheter aortic valve implantation (TAVI) using a transfemoral (TF) approach is a widely used therapeutic option for the treatment of patients with inoperable severe aortic stenosis or at high surgical risk. Technical improvements and greater operator experience have enhanced the safety of the procedure, although the rate of complications, in particular bleeding and vascular complications, is still high.

Most vascular complications can be rapidly and successfully treated by percutaneous techniques if access is adequate.1 Several authors have described strategies to manage complications via anterograde access from the contralateral femoral2,3 or the radial artery4 or via retrograde access from the ipsilateral femoral artery.5 However, the anterograde techniques described include a delayed approach to therapeutic access at the end of the procedure, when the vascular complication can hinder guidewire introduction and prevent its rapid and adequate management.

The present study evaluated the usefulness of routine placement of a wire in the therapeutic femoral artery from the contralateral femoral artery, introduced at the start of the procedure, to prevent and/or treat vascular complications.

We analyzed data from 159 consecutive patients treated by TF-TAVI at a single hospital between July 2008 and October 2012; in all patients, 18-Fr introducers and percutaneous closure with the Prostar XL device were used after implantation of the Edwards-SAPIEN XT (n=88) or Medtronic CoreValve (n=71) prosthesis.

The patients were divided into 2 sequential groups: group I consisted of patients treated conventionally (no guidewire, n=57, until July 2010), and group II was composed of patients in which a contralateral guidewire was advanced at the start of the procedure (with guide, n=102, as of August 2010). Additionally, in the final 28 patients in this group, a technical variant consisting of balloon inflation at low atmospheres in the puncture area after Prostar closure was used to facilitate hemostasis at this level. The baseline characteristics and 30-day hemorrhagic, vascular, and renal complications according to the Valve Academy Research Consortium (VARC)-2 definitions were compared to analyze therapeutic management in the event of complications.

The results are shown in the Table. Both groups had similar baseline characteristics, except for the valvular area, which was larger in group II. Vascular complications and therapeutic femoral bleeding were similar in both groups; the most common complication was incomplete arteriotomy closure with the Prostar device.


Description of Patients’ Baseline Characteristics, Complications, Vascular Complications, and Therapeutic Management

  Group I, no guidewire  Group II, with guidewire  P 
Baseline data
Patients  57  102   
Demographic and biometric factors
Age, mean (SD), y  84 (5)  83 (5)  .09 
Women  36 (63)  68 (67)  .66 
Body mass index, mean (SD)  27 (4)  28 (5)  .20 
Risk factors and comorbidity
Diabetes mellitus  14 (25)  37 (36)  .13 
Hypertension  43 (75)  87 (85)  .12 
Peripheral vascular disease  3 (5)  7 (7) 
Lung disease  10 (18)  30 (29)  .10 
Cerebrovascular disease  5 (9)  13 (13)  .45 
Heart disease
Coronary disease  24 (42)  44 (43) 
Prior angioplasty  12 (21)  18 (18)  .60 
Prior surgery  3 (5)  9 (9)  .54 
Atrial fibrillation  17 (30)  40 (39)  .24 
Ejection fraction, mean (SD), %  58 (13)  59 (15)  .58 
Aortic valve
Aortic valve area, mean (SD), cm2  0.55 (0.2)  0.63 (0.2)  .04 
Mean gradient, mean (SD), mmHg  53 (16)  50 (16)  .27 
Surgical risk
EuroSCORE I  20 (11)  17 (9)  .10 
Therapeutic prefemoral assessment
Minimum diameter, mean (SD), mm  7.19 (1.1)  6.89 (1.1)  .09 
Moderate-to-severe calcification  14 (26)  23 (23)  .38 
Moderate-to-severe tortuosity  22 (41)  39 (39)  .58 
Preprocedure laboratory workup
Creatinine, mean (SD), mg/dL  1.39 (0.6)  1.24 (0.5)  .10 
Hemoglobin, mean (SD), g/dL  12 (2)  12 (2)  .77 
Hematocrit, mean (SD), %  37 (6)  37 (5)  .73 
30-day complications (VARC-2 definitions)
Total mortality  10 (18)  6 (6)  .02 
Myocardial infarction 
Ischemic stroke  2 (4)  0 (0)  .13 
Bleeding  17 (30)  21 (21)  .19 
Potentially fatal  7 (12)  3 (3)  .04 
Major  1 (2)  6 (6)  .42 
Minor  9 (16)  12 (12)  .47 
Renal failure  12 (23)  21 (21)  .84 
Grade I  11 (19)  17 (17)  .71 
Grade 2  1 (2)  3 (3)  .64 
Grade 3  1 (1)   
Vascular complications  23 (40)  31 (30)  .54 
Major  10 (18)  7 (7)  .04 
Minor  9 (16)  19 (19)  .65 
Closure device failure  4 (7)  5 (5)  .72 
Access-related complications. Therapeutic management
Vascular or bleeding complication at therapeutic access  22 (39)  31 (30)  .29 
Type of vascular complication (nonexclusive)
Dissection  5 (9)  2 (2)  .10 
Perforation  3 (5)  3 (3)  .67 
Incomplete Prostar closure, with or without bleeding  15 (26)  25 (25)  .80 
Pseudoaneurysm  2 (4)  1 (1)  .29 
Stenosis/ischemic event  5 (9)  3 (3)  .14 
Serious hematoma  3 (5)  0 (0)  .04 
Type of bleeding
Potentially fatal  6 (11)  0 (0)  .002 
Major  1 (1.4)  6 (6)  .42 
Minor  8 (14)  11 (11)  .55 
Treatment of vascular complication
Interventional cardiology (balloon)  8 (14)  8 (8)  .21 
Interventional cardiology (stent)  5 (9)  21 (21)  .05 
Surgery  4 (7)  1 (1)  .06 
Total  10 (18)  6 (6)  .02 
Related to vascular complication  3 (5)  0 (0)  .045 
Details on patients with vascular complication
Patients  22  31   
Procedure duration, mean (SD), min  172 (53)  129 (44)  .002 
Amount of contrast material, mean (SD), mL  190 (89)  215 (89)  .30 
Transfused blood units, mean (SD)  3.4 (5)  2.4 (2)  .51 
Hospitalization duration, mean (SD), d  8.9 (9)  9.1 (7)  .98 

SD, standard deviation; VARC-2, Valve Academic Research Consortium.

Unless otherwise indicated, the data are expressed as No. (%).

Although there were no differences in the total number of vascular complications, group II showed significant reductions in serious complications, total mortality, and vascular access complications.

In the therapeutic management of complications, group I had more surgical repairs and more stents than group II (the Figure shows an example of the second group). Interventional cardiology was highly effective in the treatment of vascular complications in both groups, and bleeding was completely resolved in the 26 patients treated with a stent.


Group II patient treated by stent implantation. A: Right femoral angiography; puncture site selection (arrow). B: Angioplasty guidewire (arrows) advanced from the contralateral femoral artery. C: Angiography after Prostar closure; capillary leak syndrome of contrast material is observed in the puncture area. D: Implantation of Advanta V12 drug-eluting stent in the capillary leak syndrome area. E: Fluoroscopic image of the stent (asterisk). F: Final angiographic image.


In patients managed by surgery, the procedure was performed immediately for incontrollable bleeding in 4 patients in group I, and for ischemia at 48 hours postprocedure in the only patient who underwent surgery in group II.

The use of a contralateral guidewire in TF-TAVI procedures was initially described by Sharp et al.2 These authors observed a surgical repair rate of 70% for vascular complications, and reported that balloon compression hemostasis was able to stabilize the patient until the procedure. Buchanan et al4 proposed anterograde left radial access using a long coaxial balloon to promote hemostasis during suturing. If there was persistent bleeding, additional contralateral femoral access was used to attempt percutaneous repair of the complication.

Frerker et al5 described ipsilateral retrograde access and achieved percutaneous repair of most vascular complications with this technique, although with a higher number of minor complications related to dual ipsilateral access.

In our series, the wire was passed from the contralateral femoral artery rapidly and readily in all patients, was not associated with any complications, and allowed immediate percutaneous repair of the complication in all patients.

The use of a contralateral guidewire in TF-TAVI procedures does not decrease the incidence or type of complications, but could reduce the severity and clinical repercussions of these complications and facilitate percutaneous treatment. Because this study was sequential, experience may have led to better outcomes in the second group.

S. Stortecky, P. Wenaweser, N. Diehm, T. Pilgrim, C. Huber, A.B. Rosskopf, et al.
Percutaneous management of vascular complications in patients undergoing transcatheter aortic valve implantation.
JACC Cardiovasc Interv, 5 (2012), pp. 515-524
A.S. Sharp, I. Michev, F. Maisano, M. Taramasso, C. Godino, A. Latib, et al.
A new technique for vascular access management in transcatheter aortic valve implantation.
Catheter Cardiovasc Interv, 75 (2010), pp. 784-793
P. Genereux, S. Kodali, M.B. Leon, C.R. Smith, Y. Ben-Gal, A.J. Kirtane, et al.
Clinical outcomes using a new crossover balloon occlusion technique for percutaneous closure after transfemoral aortic valve implantation.
JACC Cardiovasc Interv, 4 (2011), pp. 861-867
G.L. Buchanan, A. Chieffo, M. Montorfano, D. Maccagni, F. Maisano, A. Latib, et al.
A “modified crossover technique” for vascular access management in high-risk patients undergoing transfemoral transcatheter aortic valve implantation.
Catheter Cardiovasc Interv, 81 (2013), pp. 579-583
C. Frerker, D. Schewel, K.H. Kuck, U.S. Md.
Ipsilateral arterial access for management of vascular complication in transcatheter aortic valve implantation.
Catheter Cardiovasc Interv, 81 (2013), pp. 592-602
Copyright © 2013. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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