Access problems with endovascular aortic valve repair
and how to handle them
Marc RHM van Sambeek, Cees-Joost Botman, Jacques Koolen,
Philippe Cuypers and Joep Teijink
Aortic stenosis is the most common valvular References:
disease in the elderly. Age, in addition to co-
morbidity is the reason why a large number of 1. de Jaegere PT, van Dijk LC, Laborde JC,
elderly patients are not referred or even rejected et al. True percutaneous implantation of
for surgical valve replacement. These patients the CoreValve aortic valve prosthesis by
may be candidates for Transcatheter Aoartic combined use of ultrasound guided vascu-
Valve Implantation (TAVI). lar access, Prostar XL and Tandemheart.
Suitabilty for this treatment mainly depends on
the quality and dimensions of the femoral and 2. Piazza N, Grube E, Gerckens U, et al.
iliac arteries due to the size of the delivery cath- Procedural and 30-day outcomes follow-
eters on which these bioprostheses are mounted. ing transcatheter aortic valve implantation
using the third generation (18Fr) CoreValve
Two TAVI systems are currently in clinical ReValving System: results from the multi-
evaluation. The Cribier-Edwards aortic valve center, expanded evaluation registry 1-year
is implanted through a 22 or 24 French arterial following CE mark approval. EuroInterv
sheath and the CoreValve System can be deliv- 2008;4:242-9.
ered through an 18 French sheath.
3. de Jaegere PT, van Dijk LC, van Sam-
The percutaneous nature of these procedures beek MRHM, et al. How should I treat a
can be argued in these patients with significant patient with severe and symptomatic aor-
atherosclerotic burden. tic stenosis who is rejected for surgical
and transfemoral valve replacement and in
Access can be achieved through the ‘regular’ whom transapical implantation is aborted?
retrograde iliac tract. If this tract is severely EuroInterv 2008;4:292-6.
obstructed and/or angulated, open access
through the axillary/subclavian artery can be
used as an alternative
Recently the largest registry was published.
Patients with symptomatic severe aortic steno-
sis and logistic Euroscore ≥ 15% and age ≥ 75
years were included. The 30-day mortality was
8% and combined rate of death, stroke and myo-
cardial infarction was 9.3%
In larger series the femoral and iliac access site
complications occur in approximately 10-15%
of cases and can be considered one of the major
drawbacks of these procedures.
The prerequisites of a successful procedure are
excellent planning, careful manipulation of the
large-bore catheters in the femoral and iliac tract
and a dedicated multidisciplinary team consist-
ing of a cardiologist and vascular surgeon pre-
pared to change and translate innovation into