Strategies to minimise bleeding secondary to large-bore vascular access complications: an ounce of prevention is worth a pound of cure

Vascular access site complications account for the majority of bleeding complications after transcatheter aortic valve implantation (TAVI) and are associated with increased morbidity and mortality1. The marked decrease in vascular access site complications over recent years reflects a combination of accurate preprocedural computed tomographic mapping of the iliofemoral axis, refined technology of delivery catheters and vascular closure devices (VCD), sophisticated puncture techniques, and reliable bailout strategies built on the collective experience of the interventional community2.

We are in a process of streamlining, optimising and economising TAVI. Therefore, a systematic and versatile algorithm for large-bore vascular access closure that integrates a cascade of safety nets is of interest. The level of complexity of large-bore vascular access and closure is minimised by being broken down into individual steps amenable to standardisation (Figure 1). Procedural planning anticipates the risk of complications, without having one’s back against the wall. Computed tomography angiographic mapping of the access route considers the distance from the puncture site to the vessel wall, vessel diameter, tortuosity, distribution of calcifications, and the location of the femoral bifurcation...