Large-bore arterial access closure after transcatheter aortic valve replacement: a systematic review and network meta-analysis

Abstract

Background As the indications to transcatheter aortic valve replacement (TAVR) expand to patients at increasingly lower risk, procedure-related vascular and bleeding complications events must be minimized. We aimed to evaluate the impact of different large-bore arterial access closure devices on clinical outcomes after TAVR. Methods We searched for papers that reported outcomes according to the type of vascular closure device/technique used after TAVR and performed a Bayesian network meta-analysis (NMA). Results Fifteen studies involving 9,259 patients who underwent access site closure using PROSTAR™ XL percutaneous vascular surgical system (Abbott Vascular, Santa Clara, CA, USA), Perclose ProGlide™ suture-mediated closure system (Abbott) or MANTATM vascular closure device (Teleflex, Morrisville, NC, USA) were included. NMA showed MANTA to have the highest likelihood of reducing a primary composite endpoint of intra-hospital death, major vascular complications and major or life-threatening bleedings (Surface Under the Cumulative Ranking curve Analysis [SUCRA] 94.8%) but this was mitigated when only randomized clinical trials and propensity-matched cohorts were included (SUCRA 56.1%). The ProGlide showed the highest likelihood to reduce major or life-threatening bleedings, especially with increasing procedural complexity, and the MANTA device to reduce major and minor vascular complications. The ProStar XL device performed poorly in all explored endpoints. Conclusions Available evidence summarized through a NMA shows that ProGlide and MANTA devices appear to be both valid VCDs globally, and to be the best options to minimize vascular complications and reduce bleeding in patients undergoing TAVR, respectively.

Use of cangrelor for complex percutaneous coronary intervention in the context of concomitant severe aortic stenosis: a case series

“…In fact, TAVI is burdened by a significant rate of procedural bleeding, which are often related to the LBAA. 2 For this reason, upfront P2Y 12 inhibition (which requires up to several hours if given orally) is often avoided in this context in order to minimize bleeding risk at the moment of LBAA before or after TAVI. Cangrelor, on the other hand, can be switched-on only after LBAA is secured, therefore allowing for a safe femoral access with minimal procedural bleeding risk.…”

“…As the use of transcatheter aortic valve implantation (TAVI) to treat symptomatic severe aortic stenosis (AS) increases, there is also a growing need for percutaneous coronary intervention (PCI) to be performed within the same TAVI procedure. 1 In such cases, pre-loading with a P2Y 12 -inhibitor exposes the patient at higher risk of bleeding because of the use of large-bore arterial access (LBAA), 2 while administering the drug at the end of the procedure might increase thrombotic complication during PCI. In light of these considerations, cangrelor, a fast-acting intravenous P2Y 12 -inhibitor with a short offset, has a potential clinical utility.…”

Computed tomography derived anatomical predictors of vascular access complications following transfemoral transcatheter aortic valve implantation: A systematic review

“… 44 Different large‐bore vascular closure methods could have an impact on access‐site complications after TAVI but these were heterogeneous and frequently not reported in the included studies. Vascular closure device failure is not uncommon, occurring in up to 8% of patients, 45 and linked with adverse iliofemoral characteristics, including small CFA diameter, 46 SFAR, 47 and calcification. 48 This could limit the routine upfront use of “one fits all” closure device strategy, instead warranting pre‐emptive use of specific devices in adverse iliofemoral morphology.…”