Clinical ResearchA Novel Iliac Morphology Score Predicts Procedural Mortality and Major Vascular Complications in Transfemoral Aortic Valve Replacement
Introduction
Dr. Alain Cribier performed the first transcatheter aortic valve replacement (TAVR) in 2002; since then more than 50,000 TAVR procedures have been performed worldwide.1 TAVR is an established alternative to open heart procedures for treatment of severe aortic valve stenosis. TAVR is performed in high-risk patients who typically have multiple comorbidities and therefore at very high risk for access-related vascular injuries.2 Vascular complications have been shown to increase morbidity and mortality in this high-risk population. As such, TAVR candidates should be carefully screened to reduce their complication rate during surgery.
Vascular access site complications remain the most common complication of TAVR. Review of the literature reveals a high degree of variability in reported complication rates, ranging from 13% to 28%.3 This variability in outcomes is likely created by inconsistencies in early reporting standards and by the introduction of newer technology in recent years. To address inconsistencies, the Valve Academic Research Consortium (VARC-2) released a set of reporting standards to be adopted for all future TAVR data.4
Independent predictors of access site vascular complications in TAVR have been identified. No study until now has presented a scoring system for the relevant predictive anatomic and patient factors. Predictive models and anatomic scoring systems have been created and validated for both EVAR5, 6 and TEVAR7 procedures. With this study, an anatomic grading scale was created to provide reliable and reproducible risk stratification of patients based on anatomy relevant to transfemoral TAVR. The scoring system was applied and correlated with major vascular complications and mortality.
Section snippets
Iliac Morphology Score Model
The Iliac Morphology Score (IMS) was created from the evaluation of computed tomography angiography (CTA) images. All measurements were taken on centerline after appropriate three-dimensional (3D) reconstruction. The IMS was developed based on key anatomical measurements recommended by literature review, multivariable statistical analysis of the cohort, and the VARC-2.
The IMS model (Table I) comprises iliac artery calcification and iliac artery minimum diameter. Each attribute is graded on a
Patient Demographics
Between February 2011 and July 2015, a total of 344 patients underwent TAVR; of those, 280 had transfemoral access. The study cohort includes only patients treated through transfemoral access that had adequate and available preoperative CTA imaging (n = 198). The cohort comprises 51% men and 49% women with a mean age of 81 years and a body mass index (BMI) of 29. The majority of patients were Caucasian (82%). Patient demographics are presented in Table IV.
Procedural Characteristics
Procedural characteristics are
Discussion
Data from the landmark PARTNER trial supports the use of TAVR as an alternative to standard therapy in patients unable to withstand open surgery. Transfemoral aortic valve repair was shown to have equal long-term outcomes when compared with surgical valve replacement.10 Three-year follow-up data suggest that TAVR patients have fewer hospitalizations and a higher functional status.11 Vascular complication rates present a key difference between traditional open surgical approaches and
Conclusion
Increased center experience and reduced valve delivery profiles have improved outcomes for TAVR, but vascular access complications remain a frequent occurrence.
An IMS composed of ipsilateral minimum iliac diameter plus iliac calcification is an excellent predictor of major vascular complications and 30-day mortality. Early vascular consultation and evaluation of the vasculature with alternative access in high IMS patients may reduce major vascular complications and 30-day mortality.
References (17)
- et al.
Stratification of outcomes after transcatheter aortic valve replacement according to surgical inoperability for technical versus clinical reasons
J Am Coll Cardiol
(2014) - et al.
Incidence, predictors, and implications of access site complications with transfemoral transcatheter aortic valve implantation
Am J Cardiol
(2012) - et al.
Anatomic severity grading score predicts technical difficulty, early outcomes, and hospital resource utilization of endovascular aortic aneurysm repair
J Vasc Surg
(2011) - et al.
Reporting standards for endovascular aortic aneurysm repair
J Vasc Surg
(2002) - et al.
Anatomic severity grading score for primary descending thoracic aneurysms predicts procedural difficulty and midterm aortic-related reinterventions and mortality after thoracic endovascular aortic repair
J Vasc Surg
(2016) - et al.
Endograft limb occlusion in EVAR: iliac tortuosity quantified by three different indices on the basis of preoperative CTA
Eur J Vasc Endovasc Surg
(2014) - et al.
Updated standardized endpoint definitions for transcatheter aortic valve implantation: The Valve Academic Research Consortium-2 consensus document
J Thorac Cardiovasc Surg
(2013) - et al.
Transfemoral aortic valve implantation: new criteria to predict vascular complications
JACC Cardiovasc Interv
(2011)
Cited by (13)
Incidence, predictors, impact, and treatment of vascular complications after transcatheter aortic valve implantation in a modern prospective cohort under real conditions
2020, Journal of Vascular SurgeryCitation Excerpt :We identified four factors of all VCs in the multivariate analysis: IMS, SIFAR, moderate-severe iliofemoral calcification, and moderate-severe iliofemoral tortuosity. Concerning IMS, Blakeslee-Carter et al13 reported that an IMS ≥5 had the best discriminatory power for predicting VCs (sensitivity, 54%; specificity, 90%). However, our results were less convincing (area under the receiver operating characteristic curve, 0.58 [95% CI, 0.40-0.76] vs 0.82 [95% CI, 0.65-0.98]).
Impact of Gender on Transcatheter Aortic Valve Implantation Outcomes
2020, American Journal of CardiologyCitation Excerpt :Women in our cohort had higher rates of peri-procedural major bleeding. Previous reports have demonstrated conflicting results, with some studies demonstrating similar rates of bleeding between men and women18 and other reports agrees with ours.11,17,19 In our cohort, bleeding was due to access site vascular complications in 46% in women and in 50% in men.
Trends in vascular complications and associated treatment strategies following transfemoral transcatheter aortic valve replacement
2020, Journal of Vascular SurgeryCitation Excerpt :Later experience from the PARTNER nonrandomized continued access registry showed notable improvements, with major bleeding occurring in 6.2% to 8.6% and major VCs in 6.2% to 9.7% of patients.13 Improved results have also been documented in recent single-center series across multiple continents, citing rates of major VC of 4.0% to 7.1% and minor VC of 9.0% to 29.3%.14-16 The incidence of iliofemoral access complications in our series is also consistent with similar reports among patients undergoing endovascular repair of the abdominal and thoracic aorta.17-19
Computed tomography derived anatomical predictors of vascular access complications following transfemoral transcatheter aortic valve implantation: A systematic review
2024, Catheterization and Cardiovascular Interventions
Disclosures: Blakeslee-Carter, Dexter, Ahanchi, Steerman, Larion, and Cain have no conflicts of interest to disclose. Mahoney is on the speaker’s bureau and is a consultant for Medtronic Inc., Edwards LifeSciences, and Boston Scientific; Panneton is on the speaker’s bureau, is a consultant, is on the scientific advisory board of Medtronic Inc., and is a consultant for Volcano.