Direct aortic route versus transaxillary route for transcatheter aortic valve replacement: a systematic review and meta-analysis

Abstract

Background The transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; however, few studies have compared their outcomes. Methods We performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. The study was prospectively registered with PROSPERO (registration number: CRD42017069788). We searched Medline, PubMed, Embase, and Cochrane databases for studies reporting the outcomes of DAo or TAx TAVR in at least 10 patients. Studies that did not use the Valve Academic Research Consortium definitions were excluded. We included studies that did not directly compare the two approaches and then pooled rates of events from the included studies for comparison. Results In total, 31 studies were included in the quantitative meta-analysis, with 2,883 and 2,172 patients in the DAo and TAx TAVR groups, respectively. Compared with TAx TAVR, DAo TAVR had a lower Society of Thoracic Surgery (STS) score, shorter fluoroscopic time, and less contrast volume use. The 30-day mortality rates were significantly higher in the DAo TAVR group (9.6%, 95% confidence interval (CI) = [8.4–10.9]) than in the TAx TAVR group (5.7%, 95% CI = [4.8–6.8]; P for heterogeneity <0.001). DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs. 5.8%, P for heterogeneity <0.001) and in the subgroup of studies with a mean STS score of ≥8 (1.6% vs. 6.2%, P for heterogeneity = 0.005). DAo TAVR was also associated with lower risks of permanent pacemaker implantation (12.3% vs. 20.1%, P for heterogeneity = 0.009) and valve malposition (2.0% vs. 10.2%, P for heterogeneity = 0.023) than was TAx TAVR. Conclusions DAo TAVR increased 30-day mortality rate compared with TAx TAVR; by contrast, TAx TAVR increased postoperative stroke, permanent pacemaker implantation, and valve malposition risks compared with DAo TAVR.

Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement ‐ A Systematic Review and Meta‐Analysis

“…On review, we found 40 previous meta‐analyses discussing the risk factors of PPM implantation, however in light of the current evidence the applicability of those studies is limited. 92 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 Most of these meta‐analyses included a smaller number of previously published studies ranging from 4 to 41 articles, missing a large amount of contemporary data. The selection criteria and measured predictors were limited with respect to conduction abnormalities evaluated, indications for TAVR, and in some incidences inclusive of SAVR patients.…”

“… References 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 …”

Percutaneous trans-axilla transcatheter aortic valve replacement

“…Transaxillary TAVR is increasingly popular among interventional cardiologists for patients ineligible for transfemoral arterial access [ 4 – 6 ]. In general, the arteries of the upper extremities are more likely to be free of atherosclerosis and calcification, even if the iliofemoral arteries are diseased [ 10 ].…”

“…Furthermore, vascular complications can be associated with a dismal prognosis. For this reason, numerous efforts have been made to develop alternative approaches [ 4 – 6 ]. The left axillary artery is an attractive alternative access route and may provide better outcomes compared to the other methods, requiring thoracotomy (transapical, direct aortic).…”

Minireview: Transaortic Transcatheter Aortic Valve Implantation: Is There Still an Indication?

“…In this patient population, TAo had a lower STS score (TAo 7.5 vs. TAx 8.9%), lower risk of stroke (TAo 2.6 vs. TAx 5.6%, p < 0.001), and a lower rate of permanent pacemaker implantation (TAo 12.3 vs. 20.1%, p = 0.009). However, the 30-day mortality rates were significantly higher in the TAo group (TAo 9.6 vs. 5.7%, p < 0.001) (35). Another meta-analysis conducted by Takagi et al compared TAx with TF, TA, and TAo access.…”