Original Article Cut-down outperforms complete percutaneous transcatheter valve implantation Markus Mach 1 , Manuel Wilbring 2 , Bernhard Winkler 1 , Konstantin Alexiou 3 , Utz Kappert 3 , Georg Delle-Karth 4 , Martin Grabenwo ¨ ger 5 and Klaus Matschke 3 Abstract Background: The ideal approach for transfemoral transcatheter aortic valve implantation is still widely debated. The objective of this study was to compare access and bleeding complications of complete percutaneous versus the surgical cut-down approach for transfemoral transcatheter aortic valve implantation. Methods: The study included 667 consecutive patients from November 2008 to December 2016, 466 in the percu- taneous group and 201 in the cut-down group. There were no significant differences in baseline characteristics between the 2 groups. Primary study endpoints were vascular access site and bleeding complications according to the Valve Academic Research Consortium II criteria. Results: Mean procedure time was shorter in the cut-down group: 93.5  22.0 (percutaneous) vs. 69  19 min (cut- down), p < 0.001. The rate of access complications was higher in the percutaneous group: 20.4% (95/466) vs. 8.5% (17/201), p ¼ 0.037; with predominantly minor complications in the percutaneous cohort: 14.4% (67/466) vs. 2.5% (5/201), p ¼ 0.04. Bleeding complications were more frequent in the percutaneous group: 21.9% (102/466) vs. 4.5% (9/201), p ¼ 0.01. Hospital mortality was 5.2% in the percutaneous group and 1.9% in the cut-down group (p ¼ 0.075). Conclusions: Surgical cut-down provided controlled access and resulted in fewer access site and bleeding complica- tions. Nonetheless, major access complications were not significantly different between the two cohorts. The two approaches must be seen as complementary techniques. A portfolio containing both techniques is the only way to provide a tailor-made and patient-orientated approach ensuring the safest access based on the individual vessel condition. Keywords Aortic valve, Catheterization, peripheral, Femoral artery, Heart valve prosthesis implantation, Hemorrhage, Vascular surgical procedures Introduction Nowadays, completely percutaneous transfemoral access is the most propagated approach for transcatheter aortic valve implantation (TAVI). 1–5 However, in centers with vascular surgical experience, there is still a lively debate about the role of surgical cut-down access in an increas- ingly less invasive surgical working environment. 6 In the early days of TAVI when sheath sizes were larger, sur- gical cut-down was the standard access for transfemoral TAVI. 4 As centers became more aggressive in tackling calcified and tortuous femoral arteries to offer less inva- sive strategies for a potentially younger and less frail Asian Cardiovascular & Thoracic Annals 2018, Vol. 26(2) 107–113 ß The Author(s) 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492318759350 journals.sagepub.com/home/aan 1 Department of Cardiovascular Surgery, Hospital Hietzing and Karl Landsteiner Institute for Cardiovascular Research, Vienna, Austria 2 Comprehensive Heart Center, University Hospital Halle (Saale), Halle (Saale), Germany 3 Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany 4 Department of Cardiology, Hospital Hietzing, Vienna, Austria 5 Sigmund Freud University, Medical Faculty, Vienna, Austria Corresponding author: Markus Mach, Hospital Hietzing, Department of Cardiovascular Surgery, Wolkersbergenstraße 1, A-1130 Vienna, Austria. Email: markus.mach@wienkav.at