Author + information
- Received January 14, 2011
- Revision received April 11, 2011
- Accepted May 25, 2011
- Published online August 1, 2011.
- Philippe Genereux, MD,
- Susheel Kodali, MD,
- Martin B. Leon, MD,
- Craig R. Smith, MD,
- Yanai Ben-Gal, MD,
- Ajay J. Kirtane, MD, SM,
- Benoit Daneault, MD,
- George R. Reiss, MD,
- Jeffrey W. Moses, MD and
- Mathew R. Williams, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Mathew R. Williams, Columbia University Medical Center, New York-Presbyterian Hospital, 173 Fort Washington Avenue, 2nd Floor, New York, New York 10032
Objectives This study sought to evaluate the technical success and clinical outcomes of an adjunctive crossover balloon occlusion technique (CBOT) combined with the 10-F Prostar percutaneous closure device (PCD) on the incidence of vascular and bleeding complications in patients after transfemoral transcatheter aortic valve implantation (TAVI).
Background Vascular closure following large-vessel access has most commonly been performed using a surgical cut-down and repair procedure.
Methods Between November 2008 and September 2010, 58 consecutive patients with severe aortic stenosis underwent TAVI via a retrograde femoral artery approach using the Edwards-SAPIEN transcatheter valve. Among these patients, 56 were treated with a CBOT using the “pre-close” technique and the 10-F Prostar system. The technical success of this new CBOT and the 30-day frequency of clinical events, including all-cause mortality, major vascular complications, and major bleeding (defined according to a modified version of the Valve Academic Research Consortium criteria), were assessed.
Results Successful closure was obtained in all but 3 patients (94.6%). The 30-day frequencies of mortality, major vascular complications, and major bleeding were 7.1%, 14.3%, and 5.4% respectively. No deaths were directly related to access site complications. Fourteen patients (25%) received at least 1 transfusion during the index hospitalization, of which 8 (57.1%) were not related to vascular complications. The mean and median hospital lengths of stay were 7.8 and 6.0 days.
Conclusions This new percutaneous adjunctive CBOT combined with the Prostar PCD resulted in controlled, safe, and successful percutaneous closure in most patients after TAVI.
Transcatheter aortic valve implantation (TAVI) has been increasingly recognized as an alternative therapeutic option for patients with severe aortic stenosis (AS) and cardiac symptoms (1–4). Recently, the first multicenter, randomized controlled trial of TAVI in patients with severe AS who were not suitable candidates for surgery demonstrated that transfemoral, balloon-expandable TAVI reduced mortality and cardiac symptoms compared with standard therapy (5). However, vascular and bleeding complications were frequent in this randomized trial (PARTNER [Placement of Aortic Transcatheter Valves]) and in other studies, and represent a significant limitation of transfemoral TAVI (6–8). Due to the combination of large-diameter delivery systems and diseased peripheral vasculature in these elderly patients with AS, an elective surgical approach to vascular access and closure was the strategy of choice in the early TAVI experience. More recently, fully percutaneous techniques have been explored in suitable patients, and if safe and effective, may be the preferred alternative to reduce local access site complications and to accelerate patient ambulation. Although both the 10-F Prostar percutaneous closure device (PCD) (Abbott Vascular Inc., Santa Clara, California) and PerClose Proglide (Abbott Vascular) devices have been used for percutaneous closure involving large sheaths, these devices have been associated with serious adverse outcomes in cases of device failure (9–14). To improve percutaneous large-sheath access site closure, an adjunctive crossover balloon occlusion technique (CBOT) was developed and tested in patients after TAVI procedures (15,16). The purpose of this report is to assess the technical success and clinical outcomes after CBOT combined with the 10-F Prostar PCD in a consecutive series of suitable patients undergoing TAVI procedures via the transfemoral approach.
Between November 2008 and September 2010, a total of 58 consecutive patients with severe AS underwent TAVI via the retrograde femoral artery approach using a 23- or 26-mm Edwards SAPIEN transcatheter valve (22- or 24-F sheath, respectively) as part of the PARTNER trial. Fifty-six of these patients were systematically treated with CBOT and a Prostar PCD system; 2 others underwent an elective surgical repair due to femoral artery pathoanatomy that was unsuitable for percutaneous closure. TAVI and CBOT were performed by an experienced team composed of interventional cardiologists and cardiothoracic surgeons at a single center (Columbia University Medical Center/New York Presbyterian Hospital, New York, New York).
Description of the CBOT
CBOT was systematically performed in each patient according to the following steps (Fig. 1): 1) fluoroscopy-guided puncture of the common femoral artery following angiographic localization of the “ideal” entry site with an iliac angiogram; 2) insertion and deployment of a 10-F Prostar PCD to “pre-close” the vessel; 3) transfemoral placement of the delivery sheath, then TAVI performed, and TAVI delivery catheter removed; 4) delivery sheath withdrawn into the common iliac artery over a 0.035-inch J-tip guidewire; 5) using a hydrophilic guidewire (J-Tip Glidewire, Terumo Medical Corporation, Somerset, New Jersey) from the contralateral side, a crossover catheter (Accu-Vu Omni Flush, AngioDynamics, Latham, New York) was advanced into the TAVI delivery sheath; 6) a stiff 0.035-inch guidewire was advanced through the crossover catheter and into the TAVI delivery sheath; 7) the crossover catheter was exchanged for a long crossover sheath (7-F or 8-F); 8) Prostar PCD sutures are tied as described in the conventional manner; 9) the TAVI delivery sheath was withdrawn gradually to just above the arteriotomy site while performing intermittent contrast injections through the crossover sheath to assess vascular injury; 10) a peripheral balloon (8 to 12 mm in diameter depending on common femoral or external iliac size) is inserted through the crossover sheath and inflated at low pressures (0.5 atm) just above the TAVI delivery sheath to allow a nontraumatic occlusion of the vessel before knot delivery; 11) the TAVI delivery sheath was removed and knots advanced to the arteriotomy; 12) peripheral balloon was deflated and hemostasis assessed via injection through crossover sheath; 13) if needed, a hydrophilic wire from the contralateral site was used to cross the puncture site and was positioned in the superficial femoral artery. The peripheral balloon was then advanced over this wire and inflated at the arteriotomy site to optimize closure; and 14) withdrawal of the wire, balloon, and crossover sheath.
Endpoints and definitions
The technical success of CBOT vascular closure was defined as the absence of significant early (during the procedure) or late (after the procedure) arteriotomy site complications requiring an unplanned surgical repair. We also assessed the 30-day frequency of all-cause mortality, major vascular complications, and major bleeding complications, defined according to a modified version of the Valve Academic Research Consortium criteria as described in the PARTNER trial (5,15). Vascular complications included complications originating from the TAVI sheath (ipsilateral), contralateral site, or from any other origin. Other endpoints included mean drop in hemoglobin, mean drop in hematocrit, number of blood transfusions, and duration of hospitalization.
Major vascular complications were defined by the presence of any of the following: 1) any thoracic aortic dissection; 2) access site or access-related vascular injury (dissection, stenosis, perforation, rupture, arteriovenous fistula, pseudoaneurysm, hematoma, irreversible nerve injury, or compartment syndrome) leading to either death, need for significant blood transfusions (>3 U), unplanned percutaneous (endovascular stent) or surgical intervention, or irreversible end organ damage; 3) distal embolization (noncerebral) from a vascular source requiring surgery or resulting in amputation or irreversible end organ damage; or 4) left ventricular perforation. Minor vascular complications were defined by the presence of any of the following: 1) access site or access-related vascular injury (dissection, stenosis, perforation, rupture, arteriovenous fistula, or pseudoaneurysms requiring compression or thrombin injection therapy, or hematomas requiring transfusion ≥2 but <4 U) not requiring unplanned percutaneous or surgical intervention and not resulting in irreversible end organ damage; 2) distal embolization treated with embolectomy and/or thrombectomy and not resulting in amputation or irreversible end organ damage; 3) failure of percutaneous access site closure resulting in interventional (endovascular stent) or surgical correction and not associated with death, need for significant blood transfusions (<4 U), or irreversible end organ damage.
Major bleeding was defined as a clear site of bleeding that met any one of the following criteria; bleeding that: 1) caused death; 2) caused a hospitalization or prolonged hospitalization ≥24 h due to treatment of bleeding; 3) required pericardiocentesis or an open and/or endovascular procedure for repair or hemostasis; 4) caused permanent disability (e.g., blindness, paralysis, hearing loss); or 5) required transfusion of >3 U of blood within a 24-h period. Minor bleeding had to meet all of the following criteria: 1) bleeding event that did not meet criteria for major bleeding; 2) clear site for bleeding; and 3) loss of hemoglobin >3 g/dl or loss of hematocrit >9%.
Angiographic outcomes were prospectively collected at the time of the procedure and angiographic endpoints were determined by consensus from an assessment team composed of 2 interventional cardiologists and 1 cardiothoracic surgeon. All clinical outcomes were prospectively determined at the time of the event or at the 30-day follow-up visit.
Continuous variables are presented as mean ± SD, medians, and percentages.
Between November 2008 and September 2010, 56 consecutive suitable patients with severe symptomatic AS underwent TAVI via the transfemoral approach using a 23-mm or 26-mm Edwards-SAPIEN transcatheter valve (22- or 24-F sheath, respectively) and were percutaneously closed using the CBOT. Baseline characteristics of the overall study population are shown in Table 1.
The mean time required to perform the CBOT (from valve deployment to suturing of the closure device) was 13.3 ± 6.7 min. Successful closure was obtained in 53 patients (94.6%). Characteristics present in all 3 cases of failure were obesity, vessel calcification, small vessel diameter, and unusually “high” arteriotomy access. In the 3 patients who failed closure by the CBOT/Prostar technique, all 3 had immediate and uneventful surgical repair aided by intraoperative hemostasis with the proximally deployed occlusion balloon.
Among the 53 patients who underwent successful closure with CBOT, primary closure was obtained without subsequent post-dilation in 24 cases (42.8% of total), whereas 29 cases needed additional interventions. Among those 29 patients, 26 (46.4% of total) required only subsequent low-pressure (0.5 atm) balloon inflation at the arteriotomy site to optimize angiographic outcomes, whereas 3 required endovascular stenting (5.4% of total). The reasons for post-dilation or endovascular stenting are shown in Table 2.
In addition to optimizing percutaneous closure device, CBOT facilitated the acute management of closure device failure in 3 patients (5.4%). In those patients, the CBOT allowed optimal hemostasis of 2 external iliac artery perforations and 1 flow-limiting dissection prior and during urgent surgical repair.
Importantly, no vascular or bleeding complications have been associated or related to the realization of the CBOT. Moreover, no complications were associated with the contralateral access site used for the CBOT. Closure of the contralateral site was performed in 47 patients (84%) with a single PerClose Proglide device, in 6 patients (11%) with an AngioSeal device, and in 3 patients (5%) by manual compression.
30-day clinical outcomes of CBOT
There were 4 deaths at 30 days, but none were related to CBOT or peripheral vascular complications (Table 3). Of the 8 major vascular complications, 3 were associated with unplanned vascular repair surgery and 3 with unplanned percutaneous intervention requiring an endovascular stent. There were no major vascular complications after the patient left the procedure room during the following 30 days. Of the 56 patients, 14 (25%) required blood transfusions. Six patients (10.7%) received transfusions for vascular complications (including hematomas), whereas 8 (14.3%) others were transfused for reasons unrelated to closure device failure or vascular access complications (Table 4).
The present study is a comprehensive report examining the results of an adjunctive CBOT in combination with the 10-F Prostar PCD on the acute angiographic findings and 30-day clinical outcomes in patients undergoing TAVI using the 23- or 26-mm Edwards SAPIEN transcatheter valve (22- or 24-F sheath). The principal findings of the study are: 1) a fully percutaneous closure combined with adjunctive CBOT is feasible and safe in most patients undergoing transfemoral TAVI with the 22- or 24-F sheath system; 2) CBOT is associated with a high rate of percutaneous closure device success and infrequent major bleeding; and 3) CBOT is helpful in the management of acute vascular complications related to transfemoral TAVI and was associated with a low rate of transfusion and urgent vascular repair.
Vascular closure following large-vessel access had previously been performed utilizing conventional surgical repair techniques. Recently, complete percutaneous closure has been shown to be feasible and successful for percutaneous endograft procedures in patients with abdominal aortic aneurysms (9,11–13,16–18). The predominant closure methods involved either a 10-F Prostar device or multiple 6-F ProGlide devices. Due to the high rate of vascular complications associated with the first generation of TAVI devices, percutaneous closure techniques have been recently adapted by many TAVI operators to improve clinical outcomes, including earlier patient ambulation (10,19,20).
The current study reports a success rate of 94.6% with the 10-F Prostar PCD when combined with adjunctive CBOT. These findings are similar to a previous report by Sharp et al. (20) (85.7%) using similar CBOT methods in 52 patients undergoing TAVI. The slightly higher rate of success reported in our cohort of patients may represent an evolution of CBOT and the more aggressive use of endovascular interventional techniques to manage vascular complications.
Major vascular complications are one of the primary complications of TAVI, and have been reported to occur in 16.2% of patients undergoing TAVI in a recent randomized trial that included both surgical as well as percutaneous closure methods (5). We observed major vascular complications in 14.3% of our patients in whom primary percutaneous closure was attempted. Importantly, CBOT was essential in our experience, not only to facilitate percutaneous closure, but also to manage vascular complications. Of note, 2 of our 8 major vascular complications were unrelated to vascular access per se (left ventricular perforation and ascending aortic dissection) and were due to other procedural technical considerations.
One of the main advantages of CBOT is the ability to rapidly recognize and efficiently manage vascular complications associated with transfemoral TAVI (Fig. 2). This advantage may ultimately result in less bleeding and fewer transfusions. In the present study, a subsequent percutaneous intervention was performed in 51.8% of the total population, either to optimize a final result (small extravasation at the arteriotomy site, nonocclusive dissection, or stenosis induced by the Prostar sutures), or to manage percutaneously a more serious complication (occlusive dissection, artery avulsion, or vessel perforation). Additionally, in the 3 patients who subsequently underwent open surgical repair, CBOT was used to achieve hemostasis intraoperatively. It is notable that the 30-day rate of major bleeding in our cohort was 5.4%, compared with 16.8% in the nonoperative arm of the PARTNER trial (5). Furthermore, among our 6 patients who had major vascular complications related to the access site, only 3 required transfusions, reflecting the potential value of the CBOT to facilitate hemostasis. Interestingly, overall in this patient cohort, most of the transfusions given during the index hospitalization were unrelated to vascular complications or to the access site.
Lately, some TAVI operators have adopted a “modified” crossover technique, with placement of a coronary wire (0.014 inch) in the superficial femoral artery from the contralateral site before insertion of the TAVI sheath. This allows access to the puncture site in case of a major vascular event without the need for a 7- or 8-F crossover sheath before TAVI sheath removal. However, this technique does not allow optimal management of the access site in patients with a suboptimal closure using an endovascular occlusion balloon as described in this paper. Furthermore, in case of severe vascular complications, this technique will require an exchange of the 0.014-inch wire for a larger crossover sheath and occlusive balloon, which may be time consuming and therefore result in major blood loss.
This study represents the experience of 4 TAVI operators performing procedures at a single academic center. Despite the prospective nature of this study, patients were strictly selected before their enrollment in the randomized PARTNER trial based on the suitability of vascular access for TAVI via the transfemoral route. Appropriate screening and patient selection is mandatory for the success of the PCD technique with a large-diameter sheath, and findings of the current study cannot be generalized to patients with severe peripheral disease. The results of this report should therefore be considered hypothesis generating, especially given the absence of a direct comparison with standard surgical repair or with percutaneous closure without the use of CBOT. Thus, prospective, randomized trials comparing surgical repair to the CBOT/PCD technique would be valuable to further evaluate the incremental clinical benefit of percutaneous closure in patients undergoing TAVI via transfemoral access.
Adjunctive CBOT combined with the Prostar PCD is feasible and resulted in a controlled, safe, and successful percutaneous closure in most patients undergoing TAVI. This technique was associated with low rates of access site complications and bleeding events. A PCD-enabled technique aided by CBOT after TAVI may be a viable alternative to conventional surgical repair when used in appropriately selected patients.
Dr. Genereux has received speaker honoraria from Edwards Lifesciences. Dr. Leon is a nonpaid member of the Scientific Advisory Board of Edwards Lifesciences and Medtronic Vascular. Dr. Smith is a nonpaid member of the Scientific Advisory Board of Edwards Lifesciences. Dr. Kodali have received consulting fees/honoraria from Edwards Lifesciences and Medtronic. Dr. Williams is a consultant for Edwards Lifesciences and Medtronic. All other authors have reported they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- aortic stenosis
- crossover balloon occlusion technique
- percutaneous closure device
- transcatheter aortic valve implantation
- Received January 14, 2011.
- Revision received April 11, 2011.
- Accepted May 25, 2011.
- American College of Cardiology Foundation
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