Ultrasound-Guided versus Fluoroscopy-Guided Femoral Access for Structural Heart Procedures: Outcomes From Transcatheter Aortic Valve Implantation and Left Atrial Appendage Closure.

BACKGROUND

Transfemoral access is the default approach for transcatheter aortic valve implantation (TAVI) and left atrial appendage closure (LAAC). Although ultrasound (US)-guided femoral puncture improves first-pass success and reduces vascular complications in randomized trials, real-world data in contemporary structural heart interventions, including both arterial and venous large-sheath access, remain limited. The authors aimed to compare US-guided vs. conventional transfemoral access in patients undergoing TAVI and LAAC.

METHODS

This single-center, retrospective cohort study included 165 consecutive patients undergoing transfemoral structural procedures between January 2022 and December 2024 (93: TAVI; 72: LAAC). Ultrasound guidance was used in 57 procedures (34.5%). Arterial and venous cohorts were analyzed separately. Primary outcomes were absolute hemoglobin decrease (ΔHb) and access-site vascular complications (hematoma, pseudoaneurysm, and arteriovenous fistula). In the arterial cohort, 1 : 1 propensity score matching was performed to adjust for baseline differences.

RESULTS

Hemoglobin decline was significantly smaller with US guidance in both venous (0.80 ± 0.95 vs. 1.50 ± 1.11 g/dL; P = .009) and arterial procedures (0.58 ± 0.97 vs. 1.29 ± 1.00 g/dL; P = .002). In the venous cohort, complication rates were numerically lower but not statistically different (3.8% vs. 17.4%; P = .143). In contrast, arterial complications were significantly reduced with US guidance. After propensity matching (31 patients per group), complications occurred in 3.2% vs. 29.0% [Absolute Risk Reduction(ARR) = 25.8%, Number Need to Treat (NNT) = 4, P = .013].

CONCLUSIONS

Ultrasound-guided transfemoral access was associated with reduced hemoglobin decline and fewer vascular complications, particularly in large-bore arterial procedures, supporting routine integration of real-time US guidance in structural interventions.