Peripheral Artery Disease and the Risk of Vascular Access Complications in Patients Undergoing Transfemoral TAVR: Insights from the Duke CT TAVR Registry
Presenter
Sebastian Estrada, MD, Duke University Hospital, Durham, NC
Sebastian Estrada, MD1, Dennis I Narcisse, MD2, Adam Banks, MD2, Susan Churchill2, Amanda Selover2, Fides R Schwartz, MD2, Daniele Marin, MD2, William Schuyler Jones, M.D.2, G. Chad Hughes, MD2, J. Kevin Harrison, MD1, Lynne M Koweek, MD2 and Sreekanth Vemulapalli, MD2, (1)Duke University Hospital, Durham, NC, (2)Duke University Medical Center, Durham, NC
Keywords: Peripheral Artery Disease (PAD) and TAVI/TAVR/Aortic Valve
Background
The degree and distribution of peripheral artery disease (PAD) influences the vascular access strategy for TAVR. Vascular access complications and bleeding are the largest modifiable drivers of costs during hospitalization for TAVR patients. We sought to assess the prevalence of PAD among patients undergoing TAVR and develop a multivariate model to identify patients at high risk of vascular access compilations or bleeding requiring transfusion.
Methods
A retrospective single center cohort study of 547 patients who underwent transfemoral TAVR from 2014 to 2017. Pre-procedure TAVR-protocoled Computed Tomography (CT) scans were analyzed by blinded reviewers for anatomic variables to assess for PAD. PAD was defined by three definitions: clinical diagnosis of PAD prior to imaging, obstructive PAD (>50% stenosis) on TAVR-CT, or non-obstructive PAD w/ moderate-severe calcification of TAVR-CT. Multivariable regression models with backwards selection were used to derive a parsimonious model to predict the likelihood of in-hospital vascular access complications or bleeding requiring transfusion.
Results
Of 547 patients, 68 (12.4%) had documented PAD prior to undergoing pre-procedural TAVR CT. TAVR-CT showed higher rates of anatomic PAD by both vascular anatomic definitions with 116 (21.2%) obstructive PAD and 274 (49.7%) non-obstructive PAD. Among the 547 patients undergoing transfemoral TAVR, 84 (15.3%) patients had in-hospital vascular access complication (8) or bleeding requiring transfusion (76). Age, lower body mass index (BMI), clinically recognized PAD, admission hemoglobin (Hgb), maximum percent stenosis, and vessel volume were included in our final model and the score was a strong predictor of vascular access complications or bleeding requiring transfusion. The model achieved a c-index of 0.830 and was calibrated with a p=0.726 consistent with a good fit.
Conclusions
PAD is under recognized prior to TAVR with higher rates on TAVR-CT than is clinically recognized. The presence of PAD, vessel volume and severity of arterial stenosis play an important role in predicting the risk of in-hospital vascular access complications or bleeding requiring transfusion.