CT-Guided Risk Stratification for Selective Femoral Protection Guidewire Use in Transfemoral TAVI

Despite device improvement and systematic procedure planning based on multislice computed tomography (MSCT), vascular and bleeding complications remain common adverse events after transfemoral transcatheter aortic valve implantation (TF-TAVI). To date, the best way to conduct a TF-TAVI procedure in order to reduce the occurrence and facilitate the treatment of vascular/bleeding complications is unknown. TF-TAVI streamlining includes skipping femoral protection strategies and might be the ideal solution for patients with low vascular risk. To quantify the incidence and clinical impact of operative iliofemoral vascular events after TF-TAVI and to identify MSCT-derived predictors that may inform selective use of femoral protection strategies. We analyzed 960 consecutive patients undergoing TF-TAVI with high-quality preprocedural MSCT imaging of the operative aorto-iliofemoral axis. The primary endpoint was 30-day vascular events, defined as a composite of operative iliofemoral access vascular complications (VARC-3) and/or need for balloon hemostasis. Complications related to the secondary access were adjudicated separately. Independent predictors were assessed using multivariable logistic regression. Vascular events occurred in 128 patients (13.3%), driven by operative access-site vascular (major or minor) complications (9.8%) and balloon hemostasis need (3.5%). Patients with vascular events were more often female and had smaller iliofemoral lumen dimensions, higher sheath-to-artery ratio (STAR), and more extensive circumferential calcification. At multivariable analysis, independent predictors were female sex (odds ratios [OR] 1.90; 95% confidence intervals [CI] 1.38-2.60; p < 0.001), STAR >1 (OR 1.63; 95% CI 1.12-2.40; p = 0.011), and calcification arc ≥90° across all 3 iliofemoral segments (common iliac, external iliac, and common femoral arteries) (OR 2.45; 95% CI 1.04-5.74; p = 0.040). Vascular events were associated with higher 30-day mortality (4.7% vs 1.3%; p = 0.022) and major bleeding (VARC-3 type 3: 3.1% vs 1.0%; p = 0.040; type 4: 1.6% vs 0.1%; p = 0.006). In conclusion, in contemporary TF-TAVI, approximately 1 in 8 patients experiences operative iliofemoral vascular events requiring peripheral bailout measures. An MSCT-derived "fragile access" profile (female sex, STAR >1, and diffuse circumferential iliofemoral calcification) may help target protection strategies. Condensed abstract In a large cohort of 960 TF-TAVI patients, operative ilio-femoral vascular events occurred in 13.3% and were associated with increased 30-day mortality and major bleeding. Patients with events had smaller ilio-femoral lumen dimensions, higher sheath-to-artery ratio (STAR), and more extensive circumferential calcification. Independent CT-guided predictors were female sex (OR 1.90), STAR >1 (OR 1.63), and calcification arc ≥90° across all three iliofemoral segments (OR 2.45). These findings support CT-based selection of femoral protection strategies, reserving ancillary access and bailout readiness for "fragile access" anatomy and reducing invasiveness when anatomy is favorable.