97Ultrasound guided vascular access puncture to decrease vascular complications of TAVR
Authors: Vincent F , Spillemaeker H , Kyheng M , Denimal T , Verdier B , Pamart T , Hertault A , Juthier F , Rauch A , Debry N , Susen S , Moussa M , Belin C , Delhaye C , Van Belle E 
Published: October 2019

Abstract

Background
Major vascular (VAC) and life-threatening or major bleeding (LT/MB) complications still represent one of the most frequent adverse outcomes of percutaneous transfemoral TAVR (TF-TAVR) and are associated with an increased risk of mortality. Ultrasound guidance technique allows to puncture in the non-calcified central and horizontal segment of common femoral artery. However the clinical impact of ultrasound (US)-guidance has never been studied in TF-TAVR in comparison of standard fluoroscopic guidance and could explain the lack of adoption of US guidance. We sought first to evaluate in our study the impact of US-guidance on the vascular and bleeding complications.

Methods
US-guidance for vascular access was implemented as the default approach in our institution in June 2013 for all TF-TAVR and was applied by all operators after a short training course. Thus, we defined three period and groups of consecutive patients according to the method of percutaneous puncture (fluoroscopic or US-guidance) and the generation of THV (2nd or 3rd gen.).
US-guided-2nd gen. group: TF-TAVR with 2nd generation THV and performed via US-guidance. This group refers to the period patients from June 2013 to November 2014 (n=119).
Fluo-guided-2nd gen. group: The last TF-TAVR with 2nd gen. THV and performed via fluoroscopic guidance (n=119).
US-guided-3rd gen. group: Patients implanted with 3rd gen. THV (SAPIEN 3, Evolut R) from November 2014 to December 2018 while US-guidance was systematic for all TF-TAVR (n=308).
Patients performed with US-guidance were 1:1 successfully matched with 95 patients performed with fluoroscopic guidance (fluo-guided group) with propensity-score (10 variables). We separately analyzed the consecutive patients of the US-guided-3rd gen. group.

Results
After propensity-matching, resulting in similar baseline characteristics, all the vascular and bleeding complications were reduced in the US-guided-2nd gen. group compared to Fluo-guided-2nd gen. group with respectively: VAC (6.3% vs 16.8%; OR=0.31; 95% CI: 0.12–0.85; p=0.023); LT/MB (22.1% vs 6.3%; OR=0.24, CI: 0.09–0.63; p=0.004); and VAC related to vascular access (12.6 vs 4.2%; OR=0.31; CI: 0.10–1.01; p=0.052). We also observed a reduction of the mean fluoroscopic time (1753±620 min vs 1228±405 min; p<0.001). No difference was observed between groups on survival (HR=0.68; CI: 0.42 to 1.10); p=0.125).
In the US-guided-3rd gen. group (n=308), the US-guided puncture achieved a rate of VAC of 3.2% (CI: 1.6–5.9) and of LT/MB of 3.6% (CI: 1.8–6.3).
In the overall population (n=546), we observed that LT/MB (p=0.02) was associated with a 1.7-fold increase of mortality risk.

Conclusion
The present study is the first and the largest to evaluate the impact of US-guidance in TF-TAVR.
We demonstrated that US-guided cannulation is able to reduce the risk of vascular and bleeding complications. These data endorses US-guidance as the standard method of puncture for TAVR.