The impact of small peripheral vessels on transcatheter aortic valve implantation outcomes: assessing vascular complications and mortality risk in a high-volume centre

Introduction The transfemoral route is the most frequently employed option for transcatheter aortic valve implantation (TAVI). We aimed to characterise a population of patients with small peripheral vessels who underwent TAVI in a high-volume centre and determine factors associated with vascular complications and all-cause mortality 30 days after the procedure. Methods Computerized tomography angiography (CTA) data and clinical data were collected from a selection of 209 patients undergoing transfemoral TAVI between January and December 2017 (fluoroscopy-guided access) and between June 2018 and May 2019 (ultrasound-guided access). Small peripheral vessels were defined by a common femoral artery with a minimal luminal diameter (MLD) of ≤5.5 mm on CTA imaging. Results In this study, 122 patients (58% of all patients; 63% women; mean age 83±5 years; median EuroScore II 4.4±2.4; median STS mortality score 4.5±2.1) had a common femoral artery MLD of ≤ 5.5 mm. Patients with small peripheral vessels were more likely to be female (63% vs. 38%), have a lower body mass index (BMI; 27.4 vs. 25.9), have higher STS mortality scores (3.38 vs. 4.47) and anaemia (57% vs. 38%); they were also less likely to have chronic obstructive pulmonary disease (28% vs. 16%), carotid disease (5% vs. 18%), and atrial fibrillation or flutter, p<0.05 for all. Access-related complications were more frequent in patients with small peripheral vessels (34% vs. 19%, p = 0.020). Thirty-nine patients with small peripheral vessels (32%) had an access-related complication: 20 (51%) had a bleeding complication; 38 (97%) had a vascular complication; and 30 (77%) had a major complication according to the Valve Academic Research Consortium-2 (VARC-2) criteria. Ultrasound-guided access was less frequently used than fluoroscopy-guided access in patients with small peripheral vessels (63% vs. 43%, p = 0.006), however, no differences relating to vascular complications were found between these groups. Patients with small peripheral vessels who had vascular complications had smaller maximum luminal diameters (6.4 vs 6.9 mm, p = 0.034), increased sheath-to-femoral artery ratio (SFAR) ratios (1.17 vs. 1.06, p = 0.012), lower total iliofemoral calcium volume (p = 0.036) and higher external iliac artery calcium volume (p = 0.023). During follow-up, patients with small peripheral vessels had higher mortality rates at 30 days post-TAVI (1% vs. 8%, p = 0.028), but not at one year post-TAVI. However, higher 30-day mortality was only observed in patients who did not have a vascular complication (12% vs. 0%, p = 0.030); these patients also presented higher EuroScore II values (median 10.3 vs. 4.3, p = 0.019). Conclusions Patients with small peripheral vessels undergoing transfemoral TAVI are more likely to have access-related complications. Thirty-day mortality in patients with small peripheral vessels is more frequent in patients with higher baseline EuroScore II values.