**3.1 Introduction**

*Vascular Access Surgery - Tips and Tricks*

Although in most of the TAVI procedures, Cardiopulmonary bypass (CPB) is not required but patient should have a full informed consent with possibility of emer-

While it is difficult to predict which patients will need temporary CPB support during or after valve deployment, usually patients with ejection fraction (<25%) with severe pulmonary hypertension, especially those requiring significant inotro-

gency midline sternotomy and use of CPB in case of complications.

pes during and after anesthetic induction are at higher risk.

Potential TAVI patients must undergo full evaluation with

**2. Preoperative assessment and planning**

• Transthoracic echocardiography (TTE)

• Cardiac computed tomography

1.Severity of aortic stenosis.

2.Anatomy of the aortic valve.

3.Aortic valve calcification.

5.Ventricular function.

6.Coronary artery disease.

• Transesophageal echocardiography (TEE)

• CT angiography of aorta and peripheral vessels

4.Annular, sinotubular, and sinus of Valsalva dimensions.

7.Height of coronary ostia from aortic annulus.

upon 10% over-sizing of the annular diameter.

the coronary ostia is less (<10 mm).

8.Ileofemoral vessel size, calcification, and tortuosity.

Patients with severe coronary artery disease and lesions which are treatable by percutaneous coronary intervention should get stents prior to the procedure. We keep patients on dual anti platelets therapy for about 6 weeks and then take them

The aortic annulus is sized at mid-systole, and the valve size is selected based

If the annulus is not adequately sized, there would be risk of improper valve size selection that could lead to paravalvular leak, valve embolization, coronary obstruction if the sinus of Valsalva is small or the distance between the annulus and

Initial TAVI evaluation should include an assessment of the following

• Coronary angiography

variables also:

**6**

for TAVI.

Transfemoral access (**Figure 2**) is the most preferred route in majority of the TAVI procedures world over [4] unless there is an increased risk of vascular complications depending on vascular size, tortuosity and calcification [5].
