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Surgical Versus Percutaneous Femoral Access for Delivery of Large-Bore Cardiovascular Devices (from the
James M McCabe1, Pei-Hsiu Huang2, David J Cohen3
1Division of Cardiology, University of Washington, Seattle, Washington.
Insights
Surgical large-bore femoral artery access for endovascular procedures does not offer risk advantages over percutaneous access. Percutaneous methods showed fewer complications and shorter hospital stays, with no impact on quality of life.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Access Techniques
Background:
- Large-bore femoral artery access is crucial for endovascular procedures like transcatheter aortic valve replacement (TAVR).
- The comparative safety and efficacy of surgical versus percutaneous access for these procedures remain unclear.
Purpose of the Study:
- To compare the rates of major vascular complications and quality of life outcomes between surgical and percutaneous large-bore femoral artery access in TAVR patients.
Main Methods:
- Analysis of 1,416 patients from the TAVR trials A, B, and registries, comparing 857 with surgical access and 559 with percutaneous access.
- Utilized propensity matching to control for confounding factors and assessed 30-day outcomes, including major vascular complications and quality of life scores.
Main Results:
- Unadjusted analysis showed fewer major vascular complications with percutaneous access (6.3% vs. 9.5%).
- After propensity matching, no significant difference in major vascular complications was observed (7.5% vs. 9.6%).
- Percutaneous access was linked to fewer total in-hospital vascular complications, shorter procedure times, and reduced length of stay.
Conclusions:
- Surgical large-bore femoral access does not provide a risk advantage over percutaneous access for TAVR.
- Percutaneous access may be associated with fewer overall complications and improved procedural efficiency.
Abstract:
It is unclear if surgical exposure confers a risk advantage compared with a percutaneous approach for patients undergoing endovascular procedures requiring large-bore femoral artery access. From the randomized controlled Placement of Aortic Transcatheter Valve trials A and B and the continued access registries, a total of 1,416 patients received transfemoral transcatheter aortic valve replacement, of which 857 underwent surgical, and 559 underwent percutaneous access. Thirty-day rates of major vascular complications and quality of life scores were assessed. Propensity matching was used to adjust for unmeasured confounders. Overall, there were 116 major vascular complications (8.2%). Complication rates decreased dramatically during the study period. In unadjusted analysis, major vascular complications were significantly less common in the percutaneous access group (35 [6.3%] vs 81 [9.5%] p = 0.032). However, among 292 propensity-matched pairs, there was no difference in major vascular complications (22 [7.5%] vs 28 [9.6%], p = 0.37). Percutaneous access was associated with fewer total in-hospital vascular complications (46 [16%] vs 66 [23%], p = 0.036), shorter median procedural duration (97 interquartile range [IQR 68 to 166] vs 121 [IQR 78 to 194] minutes, p <0.0001), and median length of stay (4 [IQR 2 to 8] vs 6 [IQR 3 to 10] days, p <0.0001). There were no significant differences in quality of life scores at 30 days. Surgical access for large-bore femoral access does not appear to confer any advantages over percutaneous access and may be associated with more minor vascular complications.
