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% 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 lesser 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.