Radial Artery Best for Secondary Access During TAVI: PULSE Registry

When it comes to secondary access during TAVI for patients with symptomatic severe aortic stenosis, the radial artery appears to be a much safer option when compared with traditional transfemoral access, an observational study suggests.

Transfemoral secondary access (TF-SA) was more common, but the overall rate of access-related vascular complications was roughly 10 times greater with that method than with transradial secondary access (TR-SA).

Based on the results, published in the December 23, 2024, issue of JACC: Cardiovascular Interventions, “I think we can presume that the radial approach should be established as the first choice for secondary access to minimize the risk for vascular or bleeding complications,” lead investigator David Grundmann, MD (University Medical Center Hamburg-Eppendorf, Germany), told TCTMD. “I think we can also state the message that apart from the primary access, which is femoral, any additional femoral puncture should be avoided in any case to prevent a further negative outcome.”

The study, which includes patients treated at 10 hospitals part of the Plug- or Suture-Based Vascular Closure After TAVR (PULSE) registry, is not a randomized controlled trial so some caution is warranted interpreting the findings, but Grundmann said that he and his colleagues would now recommend TR-SA over TF-SA.

“This data that we gathered with this publication is part of the continuous improvement of TAVR,” he said. “Obviously, the procedure has been improved over the years with better procedural planning, CT, local instead of general anesthesia, better patient selection, the heart-team process, and so on. This is just one more step in this development. We are trying to simplify the procedure while making it safer.”

With TAVI, secondary access is used for the placement of a pigtail catheter and aortography to guide implantation of the transcatheter heart valve. A second transfemoral puncture is typical, but there are data showing that this second puncture is associated with access site-related complications, say investigators. Radial access during PCI is now the default strategy because of the lowered risk of complications, and some operators have shifted to using the radial artery as the secondary access site during TAVI for the same reason.

Small Learning Curve, but Lots of Upsides

In PULSE, investigators collected data on 10,120 consecutive patients who underwent TAVI between 2016 and 2021. Of these, information on secondary access was available in 8,851 patients (median age 82.0 years; 49.1% female), with TF-SA selected in 7,165 cases and TR-SA used in 1,686 cases.

Vascular complications occurred in 0.3% of TR-SA patients and 3.2% of TF-SA patients. Of these access-related complications, 1.5% were considered major with TF-SA and 0.2% major with TR-SA (P < 0.001). In both groups, bleeding was the most common complication (0.2% with TR-SA vs 1.5% with TF-SA; P < 0.001), followed by pseudoaneurysm (0.1% with TR-SA vs 1.5% with TF-SA; P < 0.001). Up to one-third of complications in the TF-SA group required surgical repair, “emphasizing the clinical significance” of the findings, say investigators.

This data that we gathered with this publication is part of the continuous improvement of TAVR. David Grundmann

Even after 1:1 propensity matching, access site-related vascular complications were higher in the TF-SA group. Vascular complication rates related to primary access were similar in both groups. In the propensity-matched patients, the 30-day all-cause mortality rate was 1.2% and 3.6% in those treated with TR-SA and TF-SA, respectively (P = 0.021). 

Over time, the use of TR-SA increased, but TF-SA was still the most common strategy in 2021, noted investigators.

To TCTMD, Grundmann said the radial artery, especially in older patients, might have a greater degree of tortuosity. In all patients, ultrasound guidance is necessary to guide the radial puncture and reduce the risk of complications. He also noted that if there are access site-related vascular complications at the primary site, there isn’t a straightforward crossover option for TR-SA patients. However, the group didn’t observe any additional complications at the primary access site in the TR-SA group.

“There might be some negative aspects of radial access, but there are a lot of benefits as well,” he said, noting that patients treated with TR-SA had a shorter length of stay compared with TF-SA. “There are a lot of upsides. You have earlier discharge for the patients and reduced workload for the medical staff, which is an important aspect in current times where all of these resources are limited.”