Cardiac Access Surgery (TAVI)

The aim is to make the valve procedure possible and safe when the access vessels are the limiting factor. That may mean open exposure and repair of the femoral or iliac artery, an alternative arterial route, or standby capability to fix an access complication immediately. Access is one component of the heart team's broader assessment of valve disease and general health.

• TAVI candidates with small, calcified, diseased or tortuous femoral or iliac arteries
• Patients needing an alternative access route
• Other structural heart procedures requiring exposure or protection of major arteries

Suitability for the valve procedure itself is determined by the multidisciplinary heart team; the vascular assessment addresses how the device can be delivered safely.

Challenging femoral arteries

Peripheral arterial disease, previous stents, aneurysms, calcification or small vessel diameter can make catheter passage unsafe. A vascular surgeon assesses whether the artery can be prepared, exposed surgically or bypassed.

CT angiography maps the aorta, iliac and femoral arteries and informs catheter size, access route and closure strategy. The multidisciplinary review also covers bleeding risk, cardiac status and contingency plans for vascular complications. Medication and anticoagulant management follows the combined plan of the cardiac and vascular teams, provided in writing.

When the femoral arteries are unsuitable, the heart and vascular teams compare alternative routes according to vessel size, calcification, previous surgery and the equipment required. Planning includes how the artery will be exposed, controlled and repaired, and what backup strategy will be available if the planned route cannot be used safely.

Depending on the plan, the vascular surgeon may expose the femoral or iliac artery through an incision, control the vessel while the valve delivery system is introduced and repair the artery after catheter removal. Angioplasty or stenting may prepare or repair the access vessel, and alternative routes via an iliac, carotid, subclavian or other artery are used in selected cases with the cardiac team.

Multidisciplinary care

TAVI care involves cardiologists, cardiac surgeons, anaesthetists, imaging specialists and vascular surgeons. The access plan is one part of a broader assessment of valve disease and general health.

Recovery is managed within the cardiac pathway, with additional checks of the access wound and of limb or cerebral circulation according to the approach used. Vascular follow-up covers wound healing and vessel patency, alongside the cardiology team's valve surveillance.

• Bleeding and haematoma
• Pseudoaneurysm
• Arterial dissection or rupture
• Thrombosis and embolisation
• Reduced circulation to the leg
• Stroke, depending on the access route
• Nerve injury and infection
• Need for urgent open or endovascular vascular repair

Early recognition is the key: vascular complications identified promptly during or after TAVI can almost always be repaired.

Does vascular involvement mean my TAVI is riskier?

It means your access anatomy needs more planning than average. Involving a vascular surgeon early is how that extra risk is controlled rather than discovered on the table.

Transfemoral access through the groin is preferred for most TAVI procedures, but alternative vascular access may be required when the iliac or femoral arteries are too small, heavily calcified, tortuous or previously treated. The route is selected jointly by the structural heart and vascular teams after detailed CT assessment.

Alternative approaches may include surgical exposure or repair of the femoral artery and access through other arteries, depending on anatomy and institutional expertise. Patients should understand why the standard route is unsuitable, how the proposed artery will be reached and whether vascular reconstruction is expected at the end of the procedure.

The vascular component adds risks such as bleeding, arterial dissection, blockage, embolisation and limb ischaemia, although careful planning reduces these hazards. Follow-up focuses on the access site, pulses and limb symptoms as well as the cardiac result. New groin swelling, increasing pain, a cold foot or colour change after discharge requires prompt medical review.

Yarra Vascular Surgeons collaborates with cardiology and cardiac surgical teams to plan and provide surgical or alternative access for TAVI and related structural heart procedures, with the capability to manage vascular complications and reconstruct affected vessels when necessary.

Cardiology and heart teams can refer patients with challenging access anatomy for vascular assessment and combined procedural planning.