Safety and efficacy of the unilateral, suture-based, dry-closure technique in percutaneous trans-axillary aortic valve implantation

Transaxillary transcatheter aortic valve implantation (TAx-TAVI) is the most used alternative access when severe iliofemoral disease renders transfemoral access infeasible. Compared to surgical transaxillary access, a true percutaneous approach using vascular closure devices (VCD) has advantages but can be challenging. Herein, we describe the impact of the “unilateral, suture-mediated, dry-closure technique” on vascular safety and efficacy in patients undergoing true percutaneous TAx-TAVI. A total of 77 patients undergoing percutaneous TAx-TAVI were categorized into a cohort before (C1, n = 40) and after (C2, n = 37) implementation of the suture-based dry-closure technique using an upstream occlusion balloon. In C1, arteriotomy closure mainly consisted of plug-based VCD. The primary (safety) endpoint was occurrence of major or minor access-site related vascular complications in accordance with Valve Academic Research Consortium 3 criteria. Technical success rates (at exit from procedure room) were used to assess procedural efficacy. The mean age of the study population was 79 ± 7 years and 49 % were male. From C1 to C2, the Society of Thoracic Surgeons Predicted Risk of Mortality reduced numerically (from 4.1 to 3.6 %, p = 0.060). Procedures became more streamlined with use of local anesthesia in 100 % (83 % in C2) and the left axillary artery in 76 % (68 % in C2). The primary (safety) endpoint occurred in 34 % of the patients, but reduced from 45 % in C1 to 16 % in C2 ( p = 0.011). Concurrently, there was a reduction in VCD failure (45 vs 14 % [incomplete arteriotomy closure in all 5 cases], p = 0.003), bleeding complications (45 vs 14 %, p = 0.003) and bailout vascular surgery/stenting (40 % vs. 16 %, p = 0.021). Technical success was 80 % in C1 and 87 % in C2 ( p = 0.45) and median length of hospital stay reduced from 5 (25th–75th percentile: 2–7) to 3 days (25th–75th percentile: 2–5, p = 0.080). The unilateral, suture-based dry-closure technique facilitates safe and effective access management in high-risk patients selected for percutaneous TAx-TAVI procedures. • We demonstrate the impact of a unilateral, suture-based, dry-closure technique in patients undergoing true percutaneous transaxillary TAVI • Implementation of the dry closure technique mitigated access site related complications vascular closure device failures, and need for bailout vascular surgery/stenting. • The procedure became more streamlined with 100% use of local anesthesia, 76% use of left-sided transaxillary access and 87% technical success. • Improved vascular safety and procedural efficacy led to a reduction in length of hospital stay from 5 to 3 days