Transcarotid Compared With Other Alternative Access Routes for Transcatheter Aortic Valve Replacement

Abstract

Background The optimal access for patients undergoing transcatheter aortic valve replacement (TAVR) who are not candidates for a transfemoral approach has not been elucidated. The purpose of this study was to compare the safety, feasibility, and early clinical outcomes of transcarotid TAVR compared with thoracic approaches. Methods and Results From a multicenter consecutive cohort of 329 alternative-access TAVR patients (2012–2017), we identified 101 patients who underwent transcarotid TAVR and 228 patients who underwent a transapical or transaortic TAVR. Preprocedural success and 30-day clinical outcomes were compared using multivariable propensity score analysis to account for between-group differences in baseline characteristics. All transcarotid cases were performed under general anesthesia, mainly using the left common carotid artery (97%). Propensity-matched groups had similar rates of 30-day all-cause mortality (2.1% versus 4.6%; P =0.37), stroke (2.1% versus 3.5%; P =0.67; transcarotid versus transapical/transaortic, respectively), new pacemaker implantation, and major vascular complications. Transcarotid TAVR was associated with significantly less new-onset atrial fibrillation (3.2% versus 19.0%; P =0.002), major or life-threatening bleeding (4.3% versus 19.9%; P =0.002), acute kidney injury (none versus 12.1%; P =0.002), and shorter median length of hospital stay (6 versus 8 days; P <0.001). Conclusions Transcarotid vascular access for TAVR is safe and feasible and is associated with encouraging short-term clinical outcomes. Our data suggest a clinical benefit of transcarotid TAVR with respect to atrial fibrillation, major bleeding, acute kidney injury, and length of stay compared with the more invasive transapical or transaortic strategies. Randomized studies are required to ascertain whether transcarotid TAVR yields equivalent results to other alternative vascular access routes.

Comparison of the short-term safety and efficacy of transcarotid and transfemoral access routes for transcatheter aortic valve implantation

“…Results of most reports on TC-TAVI and TF-TAVI showed a satisfactory safety profile of both types of procedures. Also, TC-TAVI compared favorably to TF-TAVI in terms of the procedural success, perioperative and 30-day mortality, as well as other VARC-2 endpoints [13,23,24,27,[29][30][31]. This trend is also confirmed by our results, which are shown in Table 2 and 3.…”

“…In a meta-analysis of Wee et al [23] rate of cerebrovascular events in a group of 364 TC-TAVI was 3.8%. Chamandi et al [24] comparing TC-TAVI with TA and transaortic (TAo) showed 2.1% and 3.5% risk of stroke in those groups. On the other hand, Zhao [25] and Liu [26] In 70-80% TC-TAVI are performed through the left common carotid artery [23,27], although some of the operators still prefer the right CCA.…”

2019 Canadian Cardiovascular Society Position Statement for Transcatheter Aortic Valve Implantation

“…26,28 In addition to transapical, transaortic, and trans-subclavian routes, several alternative approaches have been developed including suprasternal innominate, transcarotid, and transcaval. [60][61][62] These have yet to be evaluated in large series, and choice of alternate access route should be on the basis of patient factors as well as local experience and expertise. If feasible, the transfemoral access route is preferred.…”

Impact of Revascularization Completeness on Outcomes of Patients with Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement

“…In a meta-analysis by Witberg et al, the impact of completeness of revascularization on the outcomes of patients undergoing PCI prior to TAVR was investigated (6 studies, 3107 patients). 21 The included studies used different cut-points of rSS (zero, 11 three, 12 eight, 22,23 nine, 24 or fourteen 25 ) to classify the extent of revascularization. Patients with more complete revascularization (indicated by a lower rSS) had a lower mortality in the mid-term (0.7 to 3 years) after TAVR.…”