The role of the vascular surgeon to optimize the management of vascular complications during transcatheter aortic valve implantation

Vascular complications represent an adverse event associated with significant morbidity and mortality in patients undergoing transcatheter aortic valve implantation (TAVI). ¹ A standardized management of the vascular access during TAVI could help to limit and prevent peri-operative vascular complications.

We read with great interest the recent publication of Filis et al. regarding the role of vascular surgeon during TAVI. ² In this retrospective single-center study, the investigators compared the incidence of vascular complications in patients undergoing TAVI over two main periods: without and with the presence of a standardized pre-operative vascular surgeon consultation. This included 382 TAVI over a five-year period. Interestingly, the authors found that the rate of vascular complications was lower (13.9% vs. 18.3%, P = 0.279) in patients who had a pre-operative vascular consultation, but the difference did not reach statistical significance. The rate of vascular complications that required the intervention of a vascular surgeon was lower (4.9% vs. 13%, P = 0.0009), and the frequency of blood transfusion was lower (3.4% vs. 11.3%, P = 0.004). These results suggest that vascular complications in this group were less severe. Finally, the pre-operative vascular surgeon consultation was identified as a predictive protective factor of vascular complications (OR = 0.345 (0.132–0.756), P = 0.015).

While other studies have described the management of percutaneous transfemoral access by a vascular surgeon during TAVI, ³ we acknowledge the additional value to current literature of the study by Filis et al. by providing comparative results with and without a pre-operative consultation with a vascular surgeon. Patients undergoing TAVI most often have cardiovascular risk factors and associated vascular diseases, representing a challenge for the percutaneous access and exposing to the risk of complications. ⁴ A standardized pre-operative vascular consultation is of interest to perform imaging examinations to detect vascular diseases that may impede or complicate the access. It allows to perform additional revascularization procedure before TAVI when necessary.

The authors used VARC-2 (Valve Academic Research Consortium-2) guidelines to evaluate the vascular complications. While this classification has provided major advances to standardize the evaluation of the vascular complications after TAVI, it does not provide a clear characterization of the peri-operative vascular outcomes from the post-operative vascular complications. ⁵ It would be of interest to evaluate the impact of having a pre-operative consultation with a vascular surgeon on the peri-operative outcomes including vascular lesions and their management.

The experience and the training of the operators have been identified as key-factors for the success of TAVI. ⁶ In the study published by Filis et al., the two groups of patients were recruited over two consecutive periods (2014–2015 and 2016–2018). We wonder whether the authors think that the increased experience of the interventional cardiologists could also contribute to explain the better outcomes of patients regarding the occurrence of vascular complications.

All in all, although this study requires confirmation of the results on a prospective longer follow-up period, it emphasizes the role of the vascular surgeon for the management of the vascular access during TAVI.