After placing a 7 Fr sheath, a JR4 or internal mammary artery catheter is used to cross into the ipsilateral common iliac artery with a wire (J tipped guidewire, angled glide wire, Wholey wire). The tip of the catheter is placed in the terminal portion of the ipsilateral external iliac artery and a cine angiogram of the ipsilateral common femoral artery is performed. A 0.018 in supportive guidewire (V18, Platinum Plus) is passed through the crossover catheter across the distal abdominal aortic bifurcation to the terminal segment of superficial femoral artery on the side in which the large caliber TAVR sheath will be placed. This wire is helpful for the crossover balloon technique at the moment of final hemostasis of the main access [54,55]. Ultrasound guidance is used as the preferred method for vascular access in some centers. It has the advantage of showing areas of calcification as well as the level of the femoral bifurcation, and better insures a puncture of the anterior wall of the common femoral artery.
In case of radial artery use as ancillary access there are two potential issues to be addressed: the standard‐length diagnostic and guiding catheters (100 or 110 cm) as well as balloon and stent catheters (150 cm) can be too short to reach the common femoral artery, especially in tall patients, unfolded aorta, tortuous iliac anatomy, etc. In order to obviate to this problem, we use left radial artery whenever possible to shorten the distance to the femoral head. It is important also to have dedicated long‐shaft material available on the shelf in case vascular complications shall arise (400 cm 0.018 in wires, peripheral balloons and stents with a shaft length of 180 cm). The second potential issue is the size of the radial sheath. Standard 6 Fr sheaths used for radial interventions might not be large enough to accommodate uncovered stents in case of ilio‐femoral dissections or stenosis. In order to increase the possibility of a successful procedure we suggest obtaining the vascular access with a 7 Fr hydrophilic 6 Fr outer‐diameter‐equivalent sheath (Glidesheath Slender, Terumo, Tokyo, Japan). With a 7 Fr inner‐diameter sheath it is possible to simultaneously protect the main access with an 0.018 in wire and keep a 5 or 6 Fr pig‐tail catheter in the aortic root for angiographic guidance of valve implantation. In case of rupture of iliac or femoral artery requiring a covered stent, the radial access is used to stop the bleeding with a balloon inflated proximally to the bleeding site, and the covered stent is delivered from the contralateral femoral access.
In patients with an ipsilateral superficial femoral artery of at least 5 mm, the main TAVR access can be “secured” by ipsilateral superficial femoral artery access with micropuncture technique, leaving a 0.018 in guidewire in the ipsilateral iliac artery and a 4 F rmicropuncture sheath that can be exchanged for a 7 Fr sheath in case a bail‐out intervention at the TAVR access site is needed.
After the main TAVR access angiogram is obtained from the ancillary access, the common femoral artery is punctured for the TAVR sheath. The angiogram is used as a roadmap for micropuncture. An injection through the crossover catheter can be used to verify the entry point of the needle in the common femoral artery (Figure 2.9). If we are not satisfied with the location of the femoral access, we withdraw the microcatheter and hold pressure for several minutes. Some operators prefer a pigtail from the contralateral access site. The terminal circle of the pigtail is placed over the target puncture site of the femoral head en face, to be used as a target for ipsilateral femoral access. A regular J tipped guidewire is placed in the microcatheter, and the microcatheter is removed. A 6 or 7 Fr dilator is placed over the wire to enlarge the arteriotomy prior to preclosure. Some operators recommend dissecting the subcutaneous tissue before 7 Fr dilator is removed for easier access to the vessel wall. Next, we use two ProGlide devices for preclosure of the arteriotomy, the first placed at the 10 o’clock position and the second device at 2 o’clock. After the second ProGlide device is deployed a stiff Amplatzer guidewire is passed through the second ProGlide. An alternative to ProGlide device is using one or two ProStar closure devices; however, the use of two Proglide devices might be simpler to use and hence more reliable in practice than a ProStar device [56].
Figure 2.9 Left panel: The white arrow shows the tip of a left internal mammary artery catheter that has been passed from the left femoral artery access over the top of the aortic bifurcation and into the right external iliac artery. This crossover catheter is used for angiography and delivery of a protective crossover wire. Right panel: Micropuncture needle having entered the right common femoral artery at the level of the white arrow. A micropuncture wire can be seen going retrograde in the right iliac and femoral system. Injection through the crossover catheter demonstrates the entry point of the micropuncture needle in the common femoral artery.
Serial dilatation of the arteriotomy is not necessary, because most TAVR devices currently require 14 Fr arterial sheaths. We sometimes use a 14 Fr dilator (and sometimes a 14 Fr sheath) before inserting the TAVR sheath. After completion of TAVR procedure, an AmplatzSuperstiff or Extrastiff wire is placed through the TAVR sheath. The first operator ties down the arteriotomy with the first ProGlide closure device with a knot pusher, while the second operator carefully removes the TAVR sheath over the guidewire. An immediate assessment of the bleeding is a direct indication of the success of the closure device. Frequently, the first preclosure device successfully closes the arteriotomy with minimal bleeding. Subsequently, by using the knot pusher, the second preclosure knot is pushed down over the wire. Until this point, the wire is still left in place in case hemostasis is not achieved. In some cases, a third or sometimes even fourth ProGlide closure device may be necessary. When hemostasis is achieved, the wire can be removed and both knots tied down again by the knot pushers.
An alternative, proposed by Kiramijyan et al. [57] consists of the adjunctive use of Angio‐Seal if the two preimplanted Proglides fail to obtain adequate hemostasis. The Angio Seal delivery sheath is introduced in the arteriotomy over the wire left in place and is then implanted in the usual manner.
We always perform a final femoral angiogram with digital subtraction via contralateral access, with either a pigtail above the aortic bifurcation, or via a catheter over the crossover wire. This latter approach requires placing a Tuohy connector on the hub end of the catheter. If there is any contrast extravasation or stenosis of the access site, it can be managed with a crossover balloon (Figure 2.10). If the results are satisfactory, the V18 wire is removed and the contralateral femoral artery is closed.
Figure 2.10 Following the completion of the procedure, crossover angiography can be used to assess the adequacy of femoral closure. (a) Needle entry at the beginning of the procedure. The entry point of the needle is in the lower one‐third of the femoral head, below the lower border of the inferior epigastric artery and above the bifurcation of the common femoral artery, in the ideal landing zone for sheath insertion. (b) Extravasation of contrast after percutaneous closure of the large sheath entry point. The black arrow shows the contrast extravasation. The dotted white arrow shows course of a 0.018 inch crossover wire. The angiogram was taken with a pigtail positioned at the distal aorta above the iliac bifurcation. (c) A balloon passed over the crossover wire and inflated at 2 atm at the site of contrast extravasation and bleeding. (d) Complete sealing of the artery at the closure site. The contrast injection was through the shaft of the balloon catheter, around the 0.018 inch wire, via a Tuohy connector on the back end of the balloon catheter.
The crossover balloon technique can also be used just before withdrawal of TAVR sheath under a controlled and safe environment. The TAVR sheath is withdrawn to
