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Meertens MM, Adam M, Beckmann A, Ensminger S, Frerker C, Seiffert M, Sinning JM, Bekeredjian R, Walther T, Beyersdorf F, Möllmann H, Balaban Ü, Eghbalzadeh K, Rudolph TK, Bleiziffer S. Non-femoral focused transaxillary access in TAVI: GARY data analysis and future trends. Clin Res Cardiol 2024:10.1007/s00392-024-02402-9. [PMID: 38436739 DOI: 10.1007/s00392-024-02402-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND In patients not suitable for transfemoral transcatheter aortic valve implantation (TAVI), several access strategies can be chosen. AIM To evaluate the use and patient outcomes of transaxillary (TAx), transapical (TA), and transaortic (TAo) as alternative access for TAVI in Germany; to further evaluate surgical cutdown vs. percutaneous TAx access. METHODS All patients entered the German Aortic Valve Registry (GARY) between 2011 and 2019 who underwent non-transfemoral TAVI were included in this analysis. Patients with TA, TAo, or TAx TAVI were compared using a weighted propensity score model. Furthermore, a subgroup analysis was performed for TAx regarding the percutaneous or surgical cutdown approach. RESULTS Overall, 9686 patients received a non-transfemoral access. A total of 8918 patients (92.1%) underwent TA, 398 (4.1%) TAo, and 370 (3.8%) TAx approaches. Within the TAx subgroup, 141 patients (38.1%) received subclavian cutdown, while 200 (54.1%) underwent a percutaneous approach. The TA patients had a significantly lower 30-day survival than TAx patients (TA 90.92% vs. TAx 95.59%, p = 0.006; TAo 92.22% vs. TAx 95.59%, p = 0.102). Comparing percutaneous and cutdown TAx approaches, no significant differences were seen. However, more vascular complications occurred (TA 1.8%, TAo 2.4%, TAx 12.2%; p < .001), and the hospital length of stay was shorter (TA 12.9 days, TAo 14.1 days, TAx 12 days; p < .001) after TAx access. CONCLUSION It may be reasonable to consider TAx access first in patients not suitable for TF-TAVI, because the 30-day survival was higher compared with TA access and the 1-year survival was higher compared with TAo access. It remains important for the heart teams to offer alternative access modalities for patients not amenable to the standard TF-TAVI approaches.
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Affiliation(s)
- Max M Meertens
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany.
| | - Matti Adam
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Andreas Beckmann
- Department of Cardiac and Pediatric Cardiac Surgery, Evanglish Clinical Center Niederrhein, Heart Center Duisburg, Duisburg, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, University Hospital of Schleswig Holstein, Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Sie Hamburg-Kiel-Lübeck, Berlin, Germany
| | - Christian Frerker
- German Center for Cardiovascular Research (DZHK), Partner Sie Hamburg-Kiel-Lübeck, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Moritz Seiffert
- German Center for Cardiovascular Research (DZHK), Partner Sie Hamburg-Kiel-Lübeck, Berlin, Germany
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | | | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, Frankfurt a. M., Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany
| | - Helge Möllmann
- The Department of Internal Medicine, St.-Johannes-Hospital Dortmund, Dortmund, Germany
| | - Ümniye Balaban
- Institute of Biostatistics and Mathematical Modelling, Goethe-University, Frankfurt, Frankfurt a. M., Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Tanja K Rudolph
- Department for General and Interventional Cardiology/Angiology, Heart and Diabetes Center North Rhine-Westphalia Bochum, University Hospital of the Ruhr University, Bad Oeynhausen, Germany
| | - Sabine Bleiziffer
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, University Hospital Ruhr-University Bochum, Bad Oeynhausen, Germany.
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Fabella A, Markovic LE, Coleman AE. Comparison of manual compression, Z-stitch, and suture-mediated vascular closure device techniques in dogs undergoing percutaneous transvenous intervention. J Vet Cardiol 2024; 51:124-137. [PMID: 38128418 DOI: 10.1016/j.jvc.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION/OBJECTIVES Manual compression has been standard of care for maintaining hemostasis after percutaneous endovascular intervention, but can be time-consuming and associated with vascular complications. Alternative closure methods include the figure-of-eight suture (Z-stitch) and vascular closure device (VCD) techniques. We hypothesized that compared to manual compression, Z-stitch and VCD would significantly reduce time-to-hemostasis after transvenous access, and the proportion of dogs with vascular patency would not differ significantly among treatments. ANIMALS Forty-six client-owned dogs undergoing percutaneous transvenous interventional procedures. MATERIALS AND METHODS Dogs with vessel diameter <5 mm were randomized to undergo manual compression or Z-stitch, while those with vessel diameter ≥5 mm were randomized to undergo manual compression, Z-stitch, or VCD. Time-to-hemostasis, bleeding scores, presence of vascular patency one day and two to three months post-procedure, and complications were recorded. Data are presented as median (95% confidence interval). RESULTS In all 46 dogs, the right external jugular vein was used. Time-to-hemostasis was significantly shorter in the Z-stitch (2.1 [1.8-2.9] minutes) compared to VCD (8.6 [6.1-11.8] minutes; P<0.001) and manual compression (10.0 [10.0-20.0] minutes; P<0.001) groups. Time-to-hemostasis was significantly shorter in the VCD vs. manual compression (P=0.027) group. Bleeding scores were significantly greater at 5 and 10 min (P<0.001 and 0.013, respectively) in manual compression, compared to Z-stitch group. There was no difference in the proportion of dogs with vascular patency between groups (P=0.59). CONCLUSIONS Z-stitch and VCD are effective venous hemostasis methods after percutaneous transvenous intervention, with Z-stitch providing the most rapid time-to-hemostasis. Both Z-stitch and VCD techniques have low complication rates and effectively maintain vascular patency.
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Affiliation(s)
- A Fabella
- Department of Small Animal Medicine and Surgery, University of Georgia, College of Veterinary Medicine, Athens, GA, 30602, USA
| | - L E Markovic
- Department of Small Animal Medicine and Surgery, University of Georgia, College of Veterinary Medicine, Athens, GA, 30602, USA.
| | - A E Coleman
- Department of Small Animal Medicine and Surgery, University of Georgia, College of Veterinary Medicine, Athens, GA, 30602, USA
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Meertens M, Wegner M, Fischnaler C, Wienemann H, Macherey S, Lee S, Kuhn E, Mauri V, Dorweiler B, Baldus S, Adam M, Ahmad W. Surgical Versus Interventional Treatment of Major Access Site Complications During Transfemoral TAVI Procedures at a Large Volume Center. J Endovasc Ther 2023:15266028231204291. [PMID: 37853703 DOI: 10.1177/15266028231204291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
PURPOSE Access-related vascular complications in transfemoral transcatheter aortic valve implantation (TAVI) can be treated endovascularly or surgically. The aim of this study was to evaluate the short- and long-term outcomes of endovascular treatment compared with surgical repair for access-related vascular complications. METHODS This retrospective study was performed from January 1, 2018, to December 31, 2020. All transfemorally treated TAVI patients in whom a surgical or endovascular treatment for an access site complication was needed were included. The primary outcome was the need for any related vascular re-operation. RESULTS In total, 1219 transfemoral TAVI procedures were conducted during the study period. 19 patients suffered an access complication requiring endovascular treatment, while 54 patients required surgical repair. No differences were seen with regard to re-operations (endovascular 15.8% vs surgical 14.8%; p=0.919), wound infections (endovascular 0% vs surgical. 11.1%; p=0.129), and wound healing disorders (endovascular 15.8% vs surgical 29.6%; p=0.237). Patients undergoing endovascular treatment were discharged earlier (endovascular 11.2 vs surgical 14.9 days; p=0.028). After surgical repair, patients received significantly more blood transfusions than endovascularly treated patients (endovascular 1.00 vs surgical 3.1 red blood cell concentrate bags; p<0.001). No differences were found regarding the new onset of walking pain, rest pain, and ischemic ulcers during follow-up. CONCLUSION In this retrospective cohort, endovascular treatment of access-related vascular complications of transfemoral TAVI procedures was safe and feasible. During the hospital stay, endovascularly treated patients received fewer blood transfusions and were discharged faster than surgically treated patients. No differences regarding clinical outcomes and re-intervention rates were seen during the follow-up. CLINICAL IMPACT Given the in this retrospective study demonstrated safety and feasibility of endovascular treatment for major access-related vascular complications, along with the in-hospital benefits and absence of follow-up disadvantages compared to surgical treatment, endovascular treatment should be considered in cases of major access-related vascular complications in transfemoral TAVI patients.
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Affiliation(s)
- Max Meertens
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Moritz Wegner
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carlos Fischnaler
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Hendrik Wienemann
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Sascha Macherey
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Samuel Lee
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Victor Mauri
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Matti Adam
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Wael Ahmad
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
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Patrick WL, Fairman AS, Desai ND, Kelly JJ, Grimm JC, Schneider DB, Szeto WY, Bavaria JE, Wang GJ. The Impact of Local vs. General Anesthesia in Patients Undergoing Thoracic Endovascular Aortic Surgery. J Vasc Surg 2022; 76:88-95.e1. [PMID: 35276270 DOI: 10.1016/j.jvs.2022.02.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE General anesthesia is associated with inherent risks that can be avoided by the use of lesser invasive anesthetic strategies. We hypothesize that examine and compare the use of local or regional anesthesia (LRA to general anesthesia (GA) in patients undergoing thoracic endovascular aortic repair (TEVAR). METHODS Patients undergoing TEVAR between 2010-2020 in the Vascular Quality Initiative were analyzed. Exclusion criteria included receipt of branched or physician modified endografts and devices extending distally beyond Zone 5. Patients were categorized as receiving LRA or GA. Center volume was reported by quartile according to annualized TEVAR volume and operative outcomes were compared using appropriate frequentists tests. Univariable and multivariable regression models for anesthesia type and operative outcomes were created to compare unadjusted and adjusted rates of each outcome. Long-term survival was estimated using a Kaplan-Meier survival estimator, while adjusted survival analysis was performed using a Cox proportional-hazards model. RESULTS Of the 17,099 patients who underwent TEVAR, 7,299 met the inclusion and exclusion criteria. Of these, 3.8% received LRA. There were no significant differences in the annual proportion of patients who received LRA from 2011 to 2020 (p = 0.49, Chi-square test for trend). Only 18.8% of patients who received LRA were treated at the highest quartile volume centers. Patients who received LRA were older and more comorbid compared to those who received GA. There were no differences in in-hospital mortality (OR = 0.79, 95% CI 0.42 to 1.38, p = 0.44) or composite of any complication (OR = 0.79, 95% CI 0.54 to 1.14, p = 0.22) between patients who received LRA compared to GA. This also applied to patients presenting with rupture. Receipt of LRA was associated with lower odds of post-operative congestive heart failure (OR = 0.19, 95% CI 0.01 to 0.89, p = 0.01) as well as decreased length of ICU (OR = 0.54, 95% CI 0.40 to 0.72, p < 0.01) and hospital length of stay (OR = 0.64, 95% CI 0.46 to 0.84, p < 0.01). LRA was not associated with decreased long-term survival compared to GA (HR 0.95, 95% CI 0.72 to 1.25, p = 0.72). CONCLUSION Despite a greater number of baseline comorbidities, patients undergoing TEVAR with LRA experienced shorter ICU and post-operative lengths of stay, with similar operative outcomes and long-term survival compared to patients who received GA.. Similar findings were found amongst the rupture cohort. LRA should be considered more frequently in select patients undergoing TEVAR.
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Affiliation(s)
- William L Patrick
- Division of Cardiovascular Surgery, University of Pennsylvania; Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania.
| | | | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania; Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania
| | | | - Grace J Wang
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Vascular and Endovascular Surgery, University of Pennsylvania
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Gennari M, Rigoni M, Mastroiacovo G, Trabattoni P, Roberto M, Bartorelli AL, Fabbiocchi F, Tamborini G, Muratori M, Fusini L, Pepi M, Muti P, Polvani G, Agrifoglio M. Proper Selection Does Make the Difference: A Propensity-Matched Analysis of Percutaneous and Surgical Cut-Down Transfemoral TAVR. J Clin Med 2021; 10:jcm10050909. [PMID: 33669044 PMCID: PMC7956334 DOI: 10.3390/jcm10050909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/22/2022] Open
Abstract
Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.
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Affiliation(s)
- Marco Gennari
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.M.); (P.T.); (M.R.); (M.A.)
- Correspondence: ; Tel.: +39-02-58-0022-96
| | - Marta Rigoni
- Department of Industrial Engineering, University of Trento, 38100 Trento, Italy;
- Department of Oncology and Health, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Giorgio Mastroiacovo
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.M.); (P.T.); (M.R.); (M.A.)
| | - Piero Trabattoni
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.M.); (P.T.); (M.R.); (M.A.)
| | - Maurizio Roberto
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.M.); (P.T.); (M.R.); (M.A.)
| | - Antonio L. Bartorelli
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20100 Milan, Italy;
| | - Franco Fabbiocchi
- Department of Invasive Cardiology, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy;
| | - Gloria Tamborini
- Department of Cardiovascular Imaging, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.T.); (M.M.); (L.F.)
| | - Manuela Muratori
- Department of Cardiovascular Imaging, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.T.); (M.M.); (L.F.)
| | - Laura Fusini
- Department of Cardiovascular Imaging, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.T.); (M.M.); (L.F.)
| | - Mauro Pepi
- Clinical Area Director, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy;
| | - Paola Muti
- Department of Oncology and Health, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada;
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20100 Milan, Italy;
| | - Gianluca Polvani
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20100 Milan, Italy;
- Chief of Cardiovascular Surgery Department, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy
| | - Marco Agrifoglio
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, 20100 Milan, Italy; (G.M.); (P.T.); (M.R.); (M.A.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20100 Milan, Italy;
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Gheorghe L, Brouwer J, Mathijssen H, Nijenhuis VJ, Rensing BJWM, Swaans MJ, Chan Pin Yin DRPP, Heijmen RH, De Kroon T, Sonker U, Van der Heyden JAS, Ten Berg JM. Early Outcomes After Percutaneous Closure of Access Site in Transfemoral Transcatheter Valve Implantation Using the Novel Vascular Closure Device Collagen Plug-Based MANTA. Am J Cardiol 2019; 124:1265-1271. [PMID: 31443900 DOI: 10.1016/j.amjcard.2019.07.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022]
Abstract
A new collagen-based MANTA vascular closure device (VCD) was developed for closing large-bore arteriotomies after transfemoral transcatheter aortic valve implantation (TAVI). We evaluated safety and feasibility at 30-day follow-up in terms of vascular and bleeding complications and mortality of the collagen-based MANTA VCD compared with the suture-based Prostar XL VCD in a cohort of 366 patients who underwent transfemoral TAVI between January 2015 and April 2018. The MANTA VCD was used in 168 patients and the Prostar XL VCD in 198 patients, with successful closure of 98.8% and 98.5%, respectively. VARC-2 defined as major vascular and bleeding complications was similar in both groups (MANTA vs Prostar XL): 0.6% versus 1.0% (p = 0.661) and 0.6% versus 1.5% (p = 0.102). Minor vascular and bleeding complications, were significantly more frequent (10.7 vs 18.8 %, p = 0.003 and 13.7 vs 19.7%, p = 0.080, respectively) in the Prostar XL cohort. Thirty-day all-cause mortality was 2.7%, without significant difference between the groups (p = 0.278). The MANTA device is a safe and feasible option for vascular access closure in patients undergoing transfemoral TAVI.
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