Anatomy of Risk: Decoding the Predictors of Vascular Access Complications in Transcatheter Aortic Valve Replacement

BACKGROUND: Despite advancements in valve implantation devices, vascular access complications (VAC) remain a significant cause of morbidity and mortality for those undergoing transcatheter aortic valve replacement (TAVR). We describe pre-operative imaging analysis of the aortoiliac and femoral arterial beds using the TransAtlantic intersociety consensus (TASC) score, ilio-femoral tortuosity, and procedural characteristics to identify anatomic risk factors predictive of VAC in TAVR. METHODS: Consecutive patients undergoing TAVR from 2012 to 2022 at a single North Dakota hospital were retrospectively reviewed. Pre-operative computed tomography angiography (CTA) was used for vascular analysis of the infrarenal aorta, iliac, and femoral vascular beds. Wilcoxon signed-rank test was used for non-normally distributed or t-test for normally distributed continuous variables and Chi-square or Fisher's exact tests for categorical variables were utilized to examine the association of each variable with vascular complications. RESULTS: One thousand eighty-nine patients were evaluated with 80 patients identified with VAC. Aortoiliac disease burden of the iliac arteries and posterior wall calcification of the common femoral artery (CFA) were predictive of VAC. Iliofemoral tortuosity and skin to CFA depth were not. Left sided CFA versus right CFA access was associated (p < 0.001). Pretreatment of diseased iliac vessels decreased odds of VAC (OR 0.21, 95% CI, 0.08-0.56). CONCLUSION: Our study highlights the importance of preoperative peripheral vascular assessment for TAVR. We identify aortoiliac disease burden, posterior CFA calcification, and left sided common femoral access as risk factors for VAC. A structured approach to the preoperative assessment may optimize planning and enhance outcomes in TAVR.