Femoral or Radial Secondary Access in TAVR: A Subanalysis From the Multicenter PULSE Registry

Background: Transradial secondary access (TR-SA) may serve as an alternative to the traditional femoral secondary access (TF-SA) for pigtail placement in transcatheter aortic valve replacement (TAVR). Objectives: The aim of this study was to assess the incidence of secondary access–related vascular complications after TR-SA or TF-SA in TAVR. Methods: The PULSE (Plug or sUture based vascuLar cloSurE after TAVR) registry retrospectively evaluated data of 10,120 patients who underwent transfemoral TAVR at 10 heart centers from 2016 to 2021. We compared TR-SA and TF-SA groups of 8,851 patients with available data regarding the secondary access location and validated observed data in 1:1 propensity score matching. Outcomes were evaluated according to Valve Academic Research Consortium 3 definitions. Results: The median age was 82.0 ± 6.9 years, and 49.1% (4,346/8,851) of patients were female. TR-SA was selected in 1,686 patients (19.0%) and TF-SA in 7,165 (81.0%) overall. Vascular complications at the secondary access occurred in 0.3% (5/1,686 [TR-SA]) vs 3.2% (232/7,165 [TF-SA]; P < 0.001) and were considered major in 0.2% (3/1,686 [TR-SA]) vs 1.5% (109/7,165 [TF-SA]) and minor in 0.1% (2/1,686 [TR-SA]) vs 1.7% (123/7,165 [TF-SA]; P < 0.001 for both). Surgical repair was required in 0 TR-SA patients and in 0.9% (66/7,165) of TF-SA patients. Primary access vascular complications were similar (11.6% (196/1,686 [TR-SA]) vs 11.5% (825/7,165 [TF-SA]); P = 0.93); bleeding type III/IV occurred less with TR-SA (2.5% [42/1,686] vs 4.7% [334/7,165] with TF-SA; P < 0.001). After propensity score matching, secondary access–related vascular complication rates remained lower for TR-SA (0.2% [1/512] vs 2.9% [15/512] for TF-SA; P < 0.001). Conclusions: During transfemoral TAVR, TR-SA was associated with lower rates of access site complications and severe bleeding compared to TF-SA. In fact, secondary access–related complications were 10× higher for TF-SA and frequently required invasive treatments. These findings challenge the fact that most TAVR procedures are still performed with TF-SA.