TAVI procedure supported by radial artery access Research among patients shows benefits of procedural adjustments

Part of the heart surgery TAVI can now be performed via the radial artery instead of the femoral artery. Research from Radboud university medical center indicates that this approach leads to fewer bleeding complications. The researchers investigated whether this technique, already common in procedures such as angioplasty, also offers advantages for the TAVI procedure, which involves replacing the aortic valve. The results have been published in JAMA Network Open.

The TAVI procedure, or Transcatheter Aortic Valve Implantation, is a minimally invasive procedure in which a new aortic valve is inserted through a femoral artery, replacing the old valve when it is narrowed. This procedure is becoming increasingly popular; approximately 14,000 TAVI procedures have been performed in the Netherlands over the past five years. For individuals aged 75-80 and for patients with medical risks, this procedure is often preferred over open-heart surgery, which carries greater risks and requires a longer recovery time.

Femoral artery

In TAVI procedures, two femoral arteries are utilized. One artery is used to introduce the aortic valve, guiding it to the correct location. The other femoral artery is used for contrast fluid, which allows for better visualization of the aorta and precise placement of the valve. In procedures such as angioplasty, access through the wrist is now standard practice, reducing the likelihood of severe bleeding.

In the TAVI procedure, this approach has not yet been adopted. Therefore, cardiologists and researchers at Radboud university medical center established a randomized study in collaboration with various centers. Patients scheduled for TAVI could participate in this study and were randomly assigned to one of two groups: the standard procedure using the two femoral arteries, or the new method, where the heart valve was introduced via the femoral artery and the contrast fluid via the radial artery.

A total of 238 patients participated in the study. The results indicated that serious bleeding requiring medical intervention occurred almost exclusively in femoral artery. Geert Versteeg, first author and physician-researcher, explains: ‘The majority of bleeding complications occurred in the groin, including the severe ones. This may be partly explained by the fact that femoral artery bleeding can go unnoticed for longer because there is more space behind the abdominal cavity for blood loss. In contrast, bleeding from the wrist is often immediately visible.’

Upper-arm vein

Additionally, the researchers made another change to the procedure. During a TAVI procedure, patients receive a temporary pacemaker, as the new valve can cause cardiac arrhythmia. This pacemaker is often removed right after the procedure, but sometimes it remains for several days. Traditionally, a femoral vein is used for this, but patients receiving contrast fluid via the wrist had their pacemaker inserted through an upper-arm vein. Niels van Royen, last author and professor of Cardiology, states: ‘This method had not been used before. The advantage is mainly that it offers more comfort. With the pacemaker in the upper-arm vein, patients are more mobile and can get out of bed faster.’

This research demonstrates that using the radial artery for contrast fluid administration has benefits, as it leads to fewer bleeding complications. Although the procedure does take slightly longer than when everything is done through femoral arteries, Van Royen expects this approach to be further integrated. ‘This is already common in angioplasty, and we have now shown that it also provides advantages in the TAVI procedure. We have been performing TAVI procedures for about fifteen years, with promising results. New aortic valves seem to function just as well after ten years as standard surgical valves. If we can reduce the risks associated with the procedure, that would be a significant step forward.’

About this publication

This article is published in JAMA Network Open: Upper- vs Lower-Extremity Secondary Access During Transcatheter Aortic Valve Implantation. A Randomized Clinical Trial – Geert A. A. Versteeg, Maxim J. P. Rooijakkers, Kimberley I. Hemelrijk, Pieter J. Vlaar, […] Michel W. A. Verkroost, Aysun Cetinyurek-Yavuz, Robin H. Heijmen, Jurrien M. ten Berg, Pim A. L. Tonino, Ronak Delewi, Niels van Royen. DOI: 10.1001/jamanetworkopen.2024.38578.

Photographer: Eric Scholten.

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