TCT: The do's and don'ts of avoiding complications during TAVI

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SAN FRANCISCO—For those performing transcatheter aortic valve implantations (TAVI), E. Murat Tuzcu, MD, has some advice: prepare, anticipate and rehearse. Tuzcu, an interventional cardiologist at Cleveland Clinic, offered interventionalists some advice on how to avoid common and uncommon vascular complications during TAVI procedures, during a twilight session Nov. 10 at the 23rd annual Transcatheter Cardiovascular Therapeutics (TCT) conference.

“Once you have any major vascular complication…it’s a problem,” Tuzcu offered. He summed data from the PARTNER Cohort B trial, which compared TAVI to the surgical approach, and found about a 16 to 17 percent vascular complication rate. “When you look at the complications of the PARTNER A trial you see how high the rate was in the TAVI group—about 11 percent or so,” Tuzcu offered.

“We had major vascular complications and bleeding was also quite high (9.3 percent in TAVI group),” he noted. However, bleeding in the surgical aortic valve replacement (SAVR) group was nearly twice as high (almost 20 percent).

“However you cut it, vascular complications are very consequential,” Tuzcu said. “Patients with vascular complications had worse mortality and it was the same thing for bleeding. Be it TAVI or SAVR, vascular complications increases mortality and reduces survival substantially.”

How can you avoid these complications? Preparation, Tuzcu offered. “You have to look at this aortic iliac system very, very carefully…every millimeter of it...[Y]ou can’t just rely on your radiologists.”

Tuzcu urged interventionalists to pay careful attention to size and calcifications. “These must be included in the equation,” he said.

“Vascular complications increase mortality so when you have borderline lesions and borderline vessels, do not push,” he said. “This will be very tempting if the non-femoral route is not appealing, but don’t push; you will regret it.” By pushing, proximal aortic dissection, an often lethal complication, can occur. Tuzcu said it will be important for the interventionalists to understand the value of imaging and to be sure to know exactly where the calcifications are.

Additionally, Tuzcu offered that the sheath to vessel size will become a very important factor during the procedure and noted that one must pay careful attention and determine the access route by the CT.

“You must puncture with a millimeter of precision and you must visualize before you put a larger sheath in,” he noted.

While stroke is another important complication to consider, Tuzcu said that it might be “slightly overblown.” The rate of major stroke was 5 percent in the PARTNER Cohort B trial, he noted.

However, he noted that stroke is “consequential because most of the patients who had a stroke did not survive it." In the future, Tuzcu noted that filter devices may be helpful. Additionally, he said that the hazard phase will be determined by the atherosclerosis burden.

“How to avoid and manage common and uncommon complications?” asked Tuzcu. “You have to prepare yourself; you have to anticipate complications and you have to rehearse the procedure with your team,” Tuzcu concluded. “Team work is essential to avoid these complications.”