Expandable Sheath Perforation in Transcatheter Aortic Valve Replacement

Aortic stenosis has been treated with transcatheter aortic valve replacement (TAVR) since 2002 by Dr. Cribier and his colleagues.¹ The most common delivery technique for catheter-based valve replacement has been the retrograde femoral artery approach. Initially, access was achieved in the clinical arena via surgical cutdown. However, due to improvements in technology, reduction in sheath size, and large-bore catheter vascular closure devices (VCD), there has been accumulating evidence supporting the percutaneous approach’s superior safety and efficacy.²

Nakamura et al³ identified the feasibility of the complete percutaneous approach and included acceptable safety and clinical benefits. The percutaneous arm versus the surgical cut-down arm of their study identified a reduction in wound infections, reduction in hospital bed days of care, and fewer bleeding complications. However, the group also noted that while the incidence of vascular events was higher in the percutaneous group, it did not affect in-hospital mortality. The Spanish TAVI Registry also reported that the percutaneous approach bore higher rates of minor vascular complications but lower rates of major bleeding at 30 days and at mid-term follow-up.⁴ Iliofemoral vascular complications weren’t common for the percutaneous group. Aortic complications were rare (0.6-1.9%), but carried a high mortality rate.

Prior to the TAVR procedure, a computed tomography angiography (CTA) is utilized in part to help identify vascular access risks. The luminal diameter of the access vessels, presence of any dissections, height of bifurcation vessels, and calcium burden are essential to evaluate and ensure a successful percutaneous approach. For the 26 mm Sapien 3 Ultra valve (Edwards Lifesciences), the product literature states the requirement of a minimum diameter of 5.5 mm for the 14 French delivery system.

During access, utilization of ultrasound guidance as well as fluoroscopic imaging should be implemented to compare specific landmarks. Use of the common femoral artery CTA  in comparison to the femoral head on fluoroscopy will provide further delineation of access entry.