Superficial femoral artery access for transcatheter aortic valve replacement

CASE REPORT – ADULT CARDIAC Interactive CardioVascular and Thoracic Surgery 24 (2017) 150–152 doi:10.1093/icvts/ivw306 Advance Access publication 22 September 2016 Cite this article as: Gennari M, Trabattoni P, Roberto M, Agrifoglio M. Superficial femoral artery access for transcatheter aortic valve replacement. Interact CardioVasc Thorac Surg 2017;24:150–2. Superficial femoral artery access for transcatheter aortic valve replacement Marco Gennaria,*, Piero Trabattonib, Maurizio Robertoa and Marco Agrifoglioa a b Department of Cardiovascular Disease, Cardiac Surgery Units, IRCCS Centro Cardiologico Monzino, Milan, Italy Department of Cardiovascular Disease, Vascular Surgery Unit, IRCCS Centro Cardiologico Monzino, Milan, Italy * Corresponding author. Department of Cardiovascular Disease, Development Innovation Cardiac Surgery Unit, IRCCS Centro Cardiologico Monzino, Via Parea 4, 20138 Milan, Italy. Tel: +39-2-58002296; fax: +39-2-58002424; e-mail: ; (M. Gennari). Received 13 June 2016; received in revised form 18 July 2016; accepted 5 August 2016 Abstract Different vascular accesses have been described for the delivery of a transcatheter aortic bioprosthesis. We report the use of the superficial femoral artery (SFA) as the arterial site of puncture with surgical cut-down. It may be a reasonable access alternative to the other classical routes, especially in the setting of either obese patients with elevated body mass index or in the presence of high femoral artery bifurcation. This route seems to be feasible with a low-profile risk. Keywords: TAVI • Aortic stenosis • Aortic valve replacement • Vascular access INTRODUCTION As the experience in transcatheter aortic valve replacement (TAVR) is growing, and the sheaths and prostheses are changing, it is useful to find new possibilities of vascular access. In selected cases, the superficial femoral artery (SFA) may be suitable and easily approached by a small surgical incision under the groin. As for the fermoral artery approach, the main risks may be local vascular complications that influence the outcome of all the transcatheter procedures [1]. CASE SERIES An SFA approach is mostly indicated in the setting of pathological obesity that may pose challenges in finding the femoral vessels at the groin and in those anatomical situations in which there is a femoral bifurcation above the inguinal ligament (Fig. 1A and B). We have used this route in 2 obese patients with a body mass index (BMI), respectively of 62, 44 and 51, 61 kg/cm2 and in 1 case of high femoral bifurcation [3 out of 641 patients, 0.47% of our transcathetera aortic valve implantation (TAVI) population] detected at the preoperative computed tomography scan. For the artery, the minimum accepted lumen diameter was 5.5 mm (for a 14 Fr sheath) at the site of puncture. The valves implanted were two 23-mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA, USA) and a 23-mm Edwards Sapien XT. The SFA was surgically exposed in the obese patients through a straight incision, starting almost 5 cm below the inguinal crease, to avoid the fat tissue from the abdomen. In the setting of high bifurcation, we make an oblique 3 cm incision just under the inguinal crease. Once exposed, the artery is manually examined for a direct evaluation of tortuosity and calcification to properly choose the optimal site for arterial function, generally 5 cm from the bifurcation in the obese patients or just 2–3 cm for the high bifurcation one (Fig. 2A). Normally, the skin incision is well below the inguinal ligament (Fig. 2B). The procedure is then performed as usual. The sheath is then removed and the puncture site directly examined for localized access damage. Because the SFA is smaller than the common femoral artery and so the sheath is more likely to wedge completely the artery, we paid special attention in this phase. The postoperative result was good in all patients. COMMENT Patients’ selection and access choice for TAVI is based upon a preoperative multidisciplinary team approach (Heart Team). Owing to the continuous evolution in the delivery sheaths, valves and vascular closure devices, it is important to search for alternative routes of delivery [2]. The results of our report show that an SFA approach is feasible in very selected patients with poor classical vascular accesses due to obesity or high anatomical bifurcation and at elevated risk for the transapical (TA) approach. SFA–TAVI is less invasive than TA implant, because it can be carried out under local anaesthesia, with a small incision or total percutaneous approach, and it does not require a chest incision. This approach was successful in all 3 patients. All prostheses were correctly positioned. No technical problems were encountered. We preferred the surgical cut-down to the percutaneous approach and relative percutaneous closure devices, because we believe that, © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. M. Gennari et al. / Interactive CardioVascular and Thoracic Surgery 151 CASE REPORT Figure 1: (A) CT scan reconstruction of a high common femoral artery bifurcation, above the inguinal ligament (red arrow). (B) Schematic drowning of the site of arterial access (black circle). CT: computed tomography. Figure 2: (A) Intraoperative picture. The site of puncture is usually on the superficial femoral artery 2–3 cm below the common femoral bifurcation (yellow arrow = profunda femoris, violet arrow = superficial femoral artery). (B) Picture of the skin incision at 3-month follow-up. Note the small thigh incision (red arrow) in the setting of pathological obesity of the abdomen. 152 M. Gennari et al. / Interactive CardioVascular and Thoracic Surgery in this particular population, it is more prudent to perform the procedure under view and vessel control (in the obese patients, it is often very difficult to manage the femoral vessels). SFA–TAVI may be an alternative access route for the delivery of the prosthesis, especially in the obese population with elevated BMI (>40) in which gaining access to the femoral vessels at the groin may be unsafe or unsuitable. Funding The authors would thank Dr. Laura Cavallotti for supporting this work. Conflict of interest: none declared. REFERENCES [1] Toggweiler S, Leipsic J, Binder RK, Freeman M, Barbanti M, Heijmen RH et al. Management of vascular access in transcatheter aortic valve replacement: part 1: basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv 2013;6:643–53. [2] Steinberger JD, McWilliams JP, Moriarty JM. Alternative aortic access: translumbar, transapical, subclavian, conduit, and transvenous access to the aorta. Tech Vasc Interv Radiol 2015;18:93–9.  (...truncated)