Totally percutaneous transfemoral transcatheter aortic valve replacement via synthetic vascular grafts: a single-center case series.

OBJECTIVE: Transfemoral (TF) vascular access is the preferred route for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis; however, patients with prior peripheral vascular surgery are often treated via alternative, more invasive access sites. The authors aimed to assess the feasibility of valve delivery via synthetic vascular grafts in patients with aortobifemoral bypass surgery. METHODS: The authors report 3 consecutive patients with peripheral vascular disease and a history of aortobifemoral bypass graft surgery who underwent TF-TAVR via direct puncture of the synthetic vascular grafts. Preprocedural computed tomography angiography (CTA) guided access site selection and vascular closure strategy in all cases. RESULTS: Prophylactic 0.014-inch safety wires were delivered to the primary access sites via a secondary access site in order to facilitate hemostasis and enable percutaneous vascular repair if necessary. Self-expanding and balloon-expandable valves were successfully delivered via synthetic grafts in all 3 procedures. A prophylactic occlusive balloon was inflated within the abdominal aorta in 1 case in order to prevent potential hemorrhage during sheath removal. Successful hemostasis was achieved in all patients, using a plug-based vascular closure device (VCD) in 1 patient and combined suture-mediated VCDs and plug-based closure devices in 2 patients. CONCLUSIONS: Percutaneous TF-TAVR with valve delivery via synthetic vascular grafts appears feasible in select patients. VCDs achieved access site hemostasis in all cases. Procedural planning based on CTA appears essential for selecting the optimal vascular access strategy.