Angiographic versus ultrasound guided femoral access for transcatheter aortic valve implantation

Aims

Both angiography-based and ultrasound (US)-based percutaneous puncture techniques are used for gaining arterial access during transfemoral transcatheter aortic valve implantation (TAVI). Despite the widespread adoption of ultrasound-based techniques in recent years, previous studies, often with small sample sizes, have not conclusively demonstrated the superiority of one of these approaches. Randomized comparative trials for procedures requiring large-bore arterial access are lacking. We therefore sought to compare outcomes of both techniques from a large single-centre institutional registry.

Methods and Results

We analysed patients that underwent transfemoral TAVI between 01/2020 and 11/2023 at a single high-volume centre. To reduce potential bias by operator preference and/or experience, the analysis was confined to cases performed by two high-volume, experienced TAVI-operators, who changed their practice from an exclusively angiography-guided to an exclusively US-guided technique in the beginning of 2022. The principal endpoint of this analysis was the occurrence of peri-procedural major or minor vascular complication related to the main femoral access site. Outcomes were adjudicated according to the Valve Academic Research Consortium (VARC)-3-classification.

A total of 1026 patients were included in this analysis; 485 patients had their arterial access using road-map angiographic guidance (RM group) and 541 patients using US-guidance (US group). The mean age of the study population was 80.7 (+/- 6.3) years, 47.7% of patients were women, and 37.1% of patients were treated with a balloon-expandable valve. Both groups were well balanced, with no significant differences regarding age, comorbidities, echocardiographic and computed tomographic features, valve type and sheath size. The principal endpoint of main access site major and minor vascular complications was significantly lower in the US group (13.4% vs. 7.9%, respectively, p=0.004). The difference was mainly driven by a reduction in minor vascular complications (12.0% vs. 6.7 %, p= 0.003), while major vascular complications were not significantly different (1.4 % vs. 1.3 %, p= 0.84). There were 57 (11.8%) total bleeding events reported in the RM-group and 29 (5.4%) in the US-group (p<0.001). Most of the bleedings were adjudicated as type 1 (6.2% vs. 3.3%, p<0.001) and type 2 (3.1% vs. 1.7%, p=0.13) bleedings, while type 3 bleedings were only rarely observed (0.4% vs. 0.4%, p=0.91). There were no significant differences regarding stroke (2.1% vs. 2.2%, p=0.86) or in-hospital mortality (0.6% vs. 0.7%, p=0.81) between both groups.

Conclusion

US-guided arterial access for transfemoral TAVI was associated with significantly lower rates of access-related vascular and bleeding complications in this large single-centre analysis. As the study was confined to operators highly experienced with angiographic guidance that switched completely to US-guidance, these findings suggest a significant benefit of the US-based approach beyond the impact of operator experience with one of both techniques.