Non-transfemoral access sites for transcatheter aortic valve replacement

Abstract

Transfemoral access is currently the standard and preferred access site for transcatheter aortic valve replacement (TAVR), though novel approaches are emerging to expand treatment options for the increasing numbers of patients with a contraindication for the traditional route. Previous publications have provided comparisons between two TAVR access sites, primarily transfemoral versus one of the novel approaches, while others have compared three or four novel approaches. The aim of this report is to provide a comprehensive summary of publications that analyse and compare the six non-transfemoral access sites currently described in the literature. These include the transapical, transaortic, axillary/subclavian, brachiocephalic, transcarotid, and transcaval approaches. Though there remains little consensus as to the superiority or non-inferiority of TAVR approaches, and there has yet to be randomized clinical trials to support published findings, with careful patient and procedural selection, outcomes for novel approaches have been reported to be comparable to standard transfemoral access when performed by skilled physicians. As such, choice of procedure is primarily based on registry data and the judgement of surgical teams as to which approach is best in each individual case. As TAVR continues to be an increasingly widespread treatment, search for the optimal access site will grow, and focus should be placed on the importance of educating surgeons as to all possible approaches so they may review and chose the most appropriate technique for a given patient.

Twelve-month outcomes of transapical transcatheter aortic valve implantation in patients with severe aortic valve stenosis

“…The second most common complication was renal failure, with a 8.2% rate, which was probably associated with surgical trauma and the systemic inflammatory response, as a possible cause of injury [14,21]. These results were similar to those previously described [18,22,23].…”

“…On the other hand, in a study by Walter et al, the authors observed lower 30-day mortality with a survival rate of 91%, but with a similar death rate of 27% at 12 months of follow-up. In summary, currently available data showed relatively lower 30-day mortality rate at 12.2 % and only 3.8% in the PARTNER TA group; 12-month mortality was 32.2% and 29.0%, respectively [5,14]. The 12-month all-cause mortality reached 24.6% but in the present study TA was the only possible method of invasive treatment in the group of patients with many comorbidities.…”

“…In severe form, such as porcelain aorta, it makes it impossible to even use minimally invasive surgical techniques [13]. In those cases, TA is the second choice for transcatheter heart valve delivery, but due to its invasive character, bleeding and other complications remain a relevant concern [14]. After starting a TAVI program in our center, the TA route was a predominant access for TAVI, at least during the first year due to factors related to patient characteristics, including extremely high risk patients with multilevel atherosclerosis, and according to CT-scan assessment TF access was not possible in those cases.…”

Right Transaxillary Transcatheter Aortic Valve Replacement Using the “Flip-n-Flex” Technique

“…19 Although left axillary artery access has favorable anatomical configuration and allows more coaxial orientation of the valve with the aortic root, thereby to the greatest degree in perpendicular to the aortic annulus, the right axillary artery is inheritably associated with major vascular tortuosity and challenging implantation angulations. 3,12,20 Therefore, this approach has yet to be widely accepted.…”

“…Because a considerable percentage of patients undergoing TAVR evaluation have peripheral vascular disease that precludes transfemoral approach TAVR, other access routes have been used as alternatives. 2,3 Among the alternative access routes that have been explored, transaxillary (TAx)-TAVR has been shown to have equivalent outcomes to transfemoral approach. [4][5][6] Compared with transaortic or transapical access routes, TAx-TAVR is less invasive and was associated with improved recovery time in studies with the CoreValve (Medtronic, Minneapolis, MN).…”