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The catheter-based treatment of valvular disease and aortic disease is emerging as an attractive alternative to treat high-risk patients. Compared to open surgery, large-bore catheter-based treatments offer less trauma, no heart-lung machine, shorter procedural times, and a significantly faster rehabilitation with acceptable short- and midterm results.
These large-bore catheter-based therapeutics require device-specific knowledge, along with procedural experience, most importantly involving vessels to gain access to the area of interest. In this article, we discuss the most common approaches used in endovascular aortic repair (EVAR), thoracic endovascular aortic repair (TEVAR), and transcatheter aortic valve replacement (TAVR) procedures: transfemoral (I), transapical (II), and the direct aortic approach (III). Alternative, less commonly used access sides such as the common carotid and the axillary artery site (IV) are outside of scope of this article.
Protocolized and excellent quality computed tomographic angiogram or time-of-flight magnetic resonance imaging/magnetic resonance angiography are critical in the preoperative evaluation of the access vessels for EVAR/TEVAR and TAVR. The femoral artery offers an adequate conduit for large-bore devices in over 90% of cases. The surgeon will look for small, tortuous, or heavily calcified iliofemoral arteries. One or two of these obstacles may be managed using endovascular techniques. However, when dealing with all three aspects, this usually requires an alternative approach (such as serial dilatation, iliac conduit, and “endo-conduit”) or another access site. Although mild tortuosity of the iliac arteries is normal, severe tortuosity and completely straightened iliac arteries (consistent with calcific changes) are both red flags for perioperative access vessel complications.
For patients with “horizontal aorta” undergoing TAVR, the transapical approach will allow for more coaxial device deployment, making the transapical route the preferred approach. For direct aortic access, the amount of plaque burden in the ascending aorta must be carefully evaluated on the preoperative imaging.
Vascular access injury is the most common complication in large-bore procedures including EVAR/TEVAR and TAVR with potentially fatal consequences. The incidence of injury to access vessels including dissection, rupture, fistula, hemorrhage, thrombosis, and pseudoaneurysm occurs in 1% to 15% of patients, complicating the procedure, ranging from claudication, severe limb ischemia, and need for bypass surgery to death.
Preoperative imaging will provide red flags for possible injury and indications for alternative access sites. An iliac artery rupture is usually suspected during a transfemoral procedure, when the iliac artery suddenly “gives away” (the pushing resistance is lost), or when there is an unexpected drop in blood pressure on removal of the large-bore sheath. In these instances, it is important to keep calm and manage the operative team resources wisely, by asking for blood products and appropriate covered stents, balloons, and surgical instruments to be brought in the room.
As soon as an iliac rupture is suspected, the large-bore sheath is reinserted in the ipsilateral position, controlling the blood loss with the tamponade effect. Most importantly, the guidewire must be kept in place throughout this critical portion of the operation. Next, a 12-Fr sheath is placed in the contralateral artery and a semicompliant balloon is expanded in the infrarenal aorta. A subsequent iliac angiogram through a pigtail catheter, after the sheath is gently withdrawn, will confirm the presence and location of the iliac artery injury. Although the contralateral balloon control of the infrarenal aorta is maintained, an appropriately sized covered stent graft is deployed over the guidewire to seal the injured vessel (Fig. 9). Open repair should be considered if the endovascular approach is not successful, or if the surgeon is not comfortable with the peripheral arterial stent grafting.
The presented access methods offer a reproducible and safe approach to perform endovascular procedures. Access site selection and management are critical aspects of the large-bore device procedure: advantages of the femoral route include ease of access, faster recovery, and the possibility of using local or regional anesthesia instead of general anesthesia. However, the long distance from the iliofemoral vessels to the area of interest harbors a higher risk of vascular damage and embolic events, including neurovascular emboli when the large-bore device is passing through the aortic arch. The advantage of the direct aortic or transapical approach is the straight route, and being close to the target zone, making the device deployment more accurate. However, neither an anterolateral thoracotomy nor a median sternotomy can be performed under local anesthesia, and the patient recovery is prolonged.