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Comparison Of External Iliac Artery To Common Femoral Artery Surgical Access For Transcatheter Aortic Valve Replacement
Justin M. George¹, Christopher Hatzis¹, Lukas Ritzer¹, Nicole Ilonzo², Peter V. Cooke¹, Sahil Khera¹, Gilbert H. Tang¹, Annapoorna S. Kini¹, Peter L. Faries¹, Rami O. Tadros¹.
¹Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA, ²Weill Cornell Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York, NY, USA.

Objective: Many patients undergoing transcatheter aortic valve replacement(TAVR) have concomitant peripheral arterial disease and require surgical access. The objective of this study is to compare preoperative medical and radiographic risk factors, procedural characteristics, and postoperative outcomes between common femoral artery and external iliac artery surgical access in TAVR patients.
Methods: A single center prospectively maintained TAVR database was analyzed for all patients undergoing surgical cutdown from 1/1/2016 to 12/31/2020. All patients had preoperative imaging to evaluate access sites. Data on demographics, risk factors, preoperative imaging, procedural characteristics, and postoperative outcomes were collected and analyzed. Selection of cutdown site was made by the vascular surgeon.
Results: 130 TAVR patients had surgical cutdowns. 82 were femoral and 48 were iliac artery. There was no significant difference between femoral and iliac artery groups in age(80.0±8.0 vs 81.1±;p=0.38), BMI, or medical risk factors. 100% of procedures in both groups were successful. Mean femoral artery size was smaller in the iliac access group(7.0±2.1mm vs. 5.1±1.4mm;p<0.001), mean sheath-to-femoral artery ratio was lower in the femoral group(0.91±0.34 vs 1.2±0.44;p<0.001) and there was higher incidence of circumferential femoral artery calcium in the iliac access group(17% vs 50%;p<0.001). There was no difference in iliac diameter(7.8±1.8mm vs 7.9±1.5mm;p=0.89) or circumferential iliac calcium(16%vs13%;p=0.80) between groups. There was no significant difference in adjunct procedures in femoral vs iliac access. There was a trend toward increased unplanned endarterectomy in the femoral access group(19% vs 6%;p=0.06). There was no difference in significant hemoglobin decrease, intraoperative or postoperative blood transfusion, hematoma, lymph leak, stroke, major adverse limb event, discharge to home vs rehabilitation facility, or 30-day reoperation rate in femoral vs iliac access. There was a higher incidence of 30-day readmission in the femoral access group(12% vs 2%;p=0.05). (Table 1)
Conclusion: External iliac artery surgical access is associated with decreased rates of unanticipated endarterectomy with no increased complication rate. The external iliac artery is an appropriate access site for large bore arterial access in select patients such as those with smaller femoral arteries, high sheath-to-femoral artery ratios, and circumferential femoral artery calcium.
Table 1-Femoral vs Iliac Artery Access for TAVR

		Access Location
		Femoral	Iliac
		N = 82	N = 48	p value
Demographic Data	Gender, Male %	55	50	0.72
	Race, %
	White	74	69	0.55
	Black	6	10	0.50
	Other	20	21	1.00
	Age, years (SD)	81.1 (8.5)	80.0 (8.0)	0.38
	Body Mass Index (SD)	26.7 (5.2)	28.0 (6.0)	0.20
	Comorbidities, %
	Hypertension	96	98	1.00
	Diabetes Mellitus	40	50	0.36
	Congestive Heart Failure	52	58	0.59
	COPD	27	35	0.33
	Coronary Artery Disease	89	96	0.21
	End-Stage Renal Disease	11	10	1.00
	Peripheral Artery Disease	67	75	0.43
	Current/Prior Tobacco Use	73	81	0.39
	Prior Femoral Cutdown, %	12	17	0.60
	Prior Femoral Percutaneous Access, %	71	65	0.56
Operative Characteristics	Elective Procedure, %	99	100	1.00
	Procedure Completed, %	100	100	1.00
	Successful Device Implementation, %	100	100	1.00
	Sheath:Femoral Artery Ratio	0.91 (0.34)	1.2 (0.44)	<0.001
	General Anesthesia, %	100	100	1.00
	Adjuncts During Index Procedure, %
	Angioplasty of Iliac Artery	11	19	0.29
	Stenting of Iliac Artery	6	6	1.00
	Lithotripsy of Iliac Artery	0	5	0.13
	Unplanned Endarterectomy	19	6	0.06
Operative Outcomes	Rates of Perioperative Complications, %
	Hemoglobin Drop >3, %	18	15	0.64
	Intraoperative Transfusion, %	12	19	0.32
	Postoperative Transfusion, %	11	17	0.42
	Postoperative Hematoma, %	5	6	0.71
	Postoperative Lymph Leak, %	0	0	1.00
	Postoperative Stroke, %	5	8	0.47
	Major Adverse Limb Events, %	2	2	1.00
	30 Day Reoperative Rate, %	2	0	0.53
	30 Day Readmission Rate, %	12	2	0.05
	30 Day Mortality Rate, %	5	4	1.00
	Length of Stay, days (SD)	4.4 (3.8)	4.4 (4.0)	0.93
	Disposition, %
	Home	76	77	1.00
	Subacute Rehab	21	21	1.00
	Death During Index Hospital Stay	4	2	1.00
Vascular Anatomy Analysis	Diameter Femoral Artery, mm (SD)	7.0 (2.1)	5.1 (1.4)	<.001
	Femoral Artery Calcification Extent, %
	Circumferential, %	17	50	<.001
	Anterior, %	3	0	0.53
	Posterior, %	54	40	0.15
	Iliac Artery Diameter, mm (SD)	7.8 (1.8)	7.9 (1.5)	0.89
	Iliac Artery Calcification Extent, %
	Circumferential, %	16	13	0.80
	Anterior, %	16	13	0.80
	Posterior, %	12	10	1.00

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