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Review of alternative access in transcatheter aortic valve replacement.

ABSTRACT: Transcatheter aortic valve replacement (TAVR) has surpassed surgical aortic valve replacement (SAVR) as the most common treatment strategy for severe symptomatic aortic stenosis over the past decade. As TAVR technology has continued to advance, it has been expanded from being an option only for extreme risk patients to now being the preferred option for the majority of patients with severe aortic stenosis. Recent trials have shown that TAVR is superior or non-inferior to SAVR even in patients at low surgical risk. One limitation of TAVR is the need for large bore vascular access. This has improved over time with smaller sheath sizes and improved delivery systems, but is still a significant issue in a patient population that often has many comorbidities including peripheral arterial disease. Early in the TAVR experience the only option for alternative access was transapical access, which has consistently been linked to increased procedural complications and worsened clinical outcomes. However, in recent years several centers have demonstrated the safety and efficacy of several alternative access strategies including transaxillary, transcarotid, transcaval, and direct aortic. There are no randomized data comparing these strategies, so access site approach is chosen by the multidisciplinary heart team based on patient anatomy and site expertise. We will review the current data in alternative access that in our view supports prioritizing a transaxillary or transcarotid strategy. In addition, we will describe our center's pre-procedural planning, peri-procedural approach, and propose an algorithm for alternative access.

SUBMITTER: Banks A

PROVIDER: S-EPMC7044091 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Review of alternative access in transcatheter aortic valve replacement.

Banks Adam A Gaca Jeff J Kiefer Todd T

Cardiovascular diagnosis and therapy 20200201 1

Transcatheter aortic valve replacement (TAVR) has surpassed surgical aortic valve replacement (SAVR) as the most common treatment strategy for severe symptomatic aortic stenosis over the past decade. As TAVR technology has continued to advance, it has been expanded from being an option only for extreme risk patients to now being the preferred option for the majority of patients with severe aortic stenosis. Recent trials have shown that TAVR is superior or non-inferior to SAVR even in patients at ...[more]

PMID: 32175229

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Project description:BACKGROUND:Transcaval access may enable fully percutaneous transcatheter aortic valve replacement (TAVR) without the hazards and discomfort of transthoracic (transapical or transaortic) access. OBJECTIVES:The authors performed a prospective, independently adjudicated, multicenter, single-arm trial of transcaval access for TAVR in patients who were ineligible for femoral artery access and had high or prohibitive risk of complications from transthoracic access. METHODS:A total of 100 patients underwent attempted percutaneous transcaval access to the abdominal aorta by electrifying a caval guidewire and advancing it into a pre-positioned aortic snare. After exchanging for a rigid guidewire, conventional TAVR was performed through transcaval introducer sheaths. Transcaval access ports were closed with nitinol cardiac occluders. A core laboratory analyzed pre-discharge and 30-day abdominal computed tomograms. The Society of Thoracic Surgeons predicted risk of mortality was 9.6 ± 6.3%. RESULTS:Transcaval access was successful in 99 of 100 patients. Device success (access and closure with a nitinol cardiac occluder without death or emergency surgical rescue) occurred 98 of 99 patients; 1 subject had closure with a covered stent. Inpatient survival was 96%, and 30-day survival was 92%. Second Valve Academic Research Consortium (VARC-2) life-threatening bleeding and modified VARC-2 major vascular complications possibly related to transcaval access were 7% and 13%, respectively. Median length of stay was 4 days (range 2 to 6 days). There were no vascular complications after discharge. CONCLUSIONS:Transcaval access enabled TAVR in patients who were not good candidates for transthoracic access. Bleeding and vascular complications, using permeable nitinol cardiac occluders to close the access ports, were common but acceptable in this high-risk cohort. Transcaval access should be investigated in patients who are eligible for transthoracic access. Purpose-built closure devices are in development that may simplify the procedure and reduce bleeding. (Transcaval Access for Transcatheter Aortic Valve Replacement in People With No Good Options for Aortic Access; NCT02280824).

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Review of alternative access in transcatheter aortic valve replacement.

Publications

Review of alternative access in transcatheter aortic valve replacement.

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