Low femoral artery puncture for transfemoral TAVR

Abstract Background Access site complications remain common during transfemoral transcatheter aortic valve replacement (TAVR). Femoral arterial access is conventionally performed at the level of the mid-femoral head. Anatomical studies have suggested that a low puncture height below the mid-femoral height may be optimal but there is little clinical evidence on the safety of this approach. Objectives We evaluated vascular and bleeding complications following intended low femoral arterial puncture compared to intended conventional height puncture for patients undergoing transfemoral TAVR. Methods Patients undergoing percutaneous transfemoral TAVR between 2014 and 2022 at a tertiary cardiothoracic centre in the North East of England were included. Procedures with intended conventional mid-femoral puncture were compared with procedures with intended low-femoral puncture. Femoral angiograms were analysed for sheath insertion height and anatomical landmarks. The primary endpoint was a composite of in-hospital death, major vascular access-related complications, major/life-threatening bleeding, and unplanned endovascular intervention. Secondary endpoints include individual components of the primary endpoint and rates of minor vascular access-related complications, minor bleeding, myocardial infarction, stroke or TIA, acute kidney injury, and post-procedure pacemaker implantation. Bleeding and vascular complications were defined by the Valve Academic Research Consortium-2 criteria. Results Out of 917 transfemoral TAVR procedures, there were 509 patients in the intended low puncture group and 408 patients in the intended conventional puncture group. Optimal puncture was achieved more frequently in the low puncture group than in the conventional puncture group (95.7% vs 65.1%; p 0.001). Suboptimal high puncture occurred more frequently in the conventional puncture group (34.9% vs 4.3%; p 0.001). The composite endpoint occurred in 8/509 patients (1.6%), who underwent TAVR with a low femoral puncture target strategy in comparison to 19/407 patients (4.7%), who underwent TAVR with a conventional femoral puncture target strategy. A low puncture strategy resulted in statistically lower rates of unplanned vascular intervention (2.5% vs 0.4% p = 0.008). There were no safety issues identified with low femoral artery puncture. Conclusions Low femoral puncture for transfemoral arterial access during TAVR is safe, leads to a higher rate of optimal puncture height, and is associated with lower rates of access-related major vascular complications, bleeding and unplanned vascular intervention compared to conventional height puncture. Low femoral puncture may be the preferred access height for transfemoral TAVR.