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A novel iliac morphology score predicts procedural mortality and major vascular complications in Transfemoral Aortic Valve Replacement
Juliet Blakeslee-Carter, BS, David Dexter, MD, Paul Mahoney, MD, Sebastian Larion, MD, Sadaf Sadie Ahanchi, MD, Samuel Steerman, MD, Brandon Cain, MD, Sarah Sourbeer, MD, Jean Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
OBJECTIVES:
Vascular complications remain a significant technical challenge for the transfemoral TAVR approach. Our aim was to create an iliac artery morphology score (IMS) to predict major vascular complications for TAVR.
METHODS:
We performed a retrospective review of all transfemoral TAVR patients from 2011-2015
(N =280). Iliofemoral arterial measurements were obtained with CTA 3D reconstructions images. Vascular complications were defined by Valve Academic Research Consortium (VARC-2) criteria. Statistical analyses were performed utilizing chi-square, student’s t test, and binomial regression.
RESULTS:
Vascular complications were seen in forty-two patients (15%). Major and minor vascular complication rates were 3.6% (n=10) and 11.4% (n=32) respectively. Fifty-three patients (19%) required vascular surgery consultation. A total of 31 patients (11%) required surgical or percutaneous vascular interventions.
The IMS was developed by evaluating the iliac segments of 194 patients. Arterial size and calcification were given a value of 0-3 based on severity (Table 1). Univartiate analysis identified gender, iliac diameter, iliac calcification, and access type (open vs. percutaneous) as predictors of major complications. The IMS was composed of ipsilateral minimum iliac diameter and iliac calcifications based on AUROC analysis (p<.05, AUROC =.82). Multivariate analysis identified gender and IMS as independent predictors of major complications. The mean score for the cohort was 3.4 (range 0-6). Patients were divided into high (IMS≥5, n=55) and low risk (IMS<5, n=139) groups based on the inflection point for specificity (73%) and sensitivity (83%). The high risk group had smaller iliac diameters, areas, and luminal volumes, and a higher rate of major vascular complications (9% vs 1%, p<.05). The mortality rate in the high score group was 9% and 1.4% in low score group (p<.05, AUROC=.72). A patient risk score (PRS) was created to evaluate morphologic and patient factors that predict VARC-2 major complications (AUROC=.88) Factors included in the patient risk score are shown in table 1. The PRS identified 59 patients as high risk (PRS≥7).
CONCLUSIONS:
An IMS composed of ipsilateral minimum iliac diameter plus iliac calcification is an excellent predictor of major vascular complications and mortality. Alternative access in patients with high IMS may reduce major vascular complications and procedural mortality.
Table 1. Patient Factors| Variable | 0 | 1 | 2 | 3 | | Calcification*§ | none | <25% vessel length | 25-50% Vessel Length | >50% of vessel length or any circumferential point | | Minimum Diameter (mm)*§ | > 7.1 | 6.4 < x ≤ 7.1 | 5.5 < x ≤ 6.4 | ≤ 5.5 | | Minimum Area (mm2) | >52 | 43 < x ≤ 52 | 33 < x ≤ 43 | ≤ 33 | | Minimum Volume (mm3) | > 5.2 | 4.3 < x ≤ 5.2 | 3.0 < x ≤ 4.3 | ≤ 3.0 | | Gender § | Male | Female | − | − | | Age (years)§ | ≤78 | 78 < x ≤ 83 | 83 < x ≤ 86 | < 86 | | * Iliac Morphology Score | § Patient Risk Score | | |
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