A Comparison of Two Vascular Closure Strategies in Transcatheter Aortic Valve Replacement: Suture and Plug versus Suture Alone - A Systematic Review and Meta-Analysis.

INTRODUCTION

Vascular complications following transcatheter aortic valve replacement (TAVR) significantly contribute to morbidity and mortality. Conventional suture-based closure technique has been widely utilized for large-bore arterial access closure. Recent findings on hybrid strategy combining plug and suture-based devices has been on spotlight as it may improve the hemostatic efficacy and lower the access-site related complications and clinical outcomes.

METHODS

We performed a systematic review and meta-analysis of studies comparing a suture-based approach with a hybrid closure strategy (suture+plug) in aortic stenosis patients undergoing TAVR. Included studies were appraised following the Cochrane Risk of Bias and Newcastle-Ottawa Scale tools. Forest plots were extracted in Review Manager with a main outcome of pooled-risk ratio (RR). The primary endpoint was the composite of access-site related vascular complications as defined by Valve Academic Research Consortium criteria whilst secondary end-points were in-hospital bleeding, closure device failure, mortality, and unplanned endovascular or surgical intervention.

RESULTS

Six eligible studies encompassing 2,064 patients were analyzed. Compared with suture-based closure, hybrid closure exhibited a lower rate of vascular complications (pooled-RR 0.46; 95% confidence interval [CI], 0.38-0.57; p < 0.001), closure device failure (pooled-RR 0.35; 95% CI, 0.13-0.96; p = 0.04), in-hospital bleeding events (pooled-RR 0.38; 95% CI, 0.26-0.55; p < 0.001), and mortality (pooled-RR 0.51; 95% CI, 0.26-0.99; p = 0.049). Unplanned endovascular or surgical intervention was no different among two groups (pooled-RR 0.42; 95% CI, 0.17-1.06; p = 0.07).

CONCLUSION

Hybrid vascular closure strategy offers better efficacy with fewer complications amongst patients undergoing TAVR, directing the clinical adoption of hybrid techniques, although further large-scale multicenter studies are warranted to confirm the benefit and optimize patient selection.