Related Experiment Video
Updated: Apr 30, 2026
Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation
Published on: August 8, 2025
Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients: initial human
Adam B Greenbaum1, William W O'Neill1, Gaetano Paone2
1Institute for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
Insights
This study introduces caval-aortic access for transcatheter aortic valve replacement (TAVR) in patients with no other options. This novel approach successfully enabled TAVR, offering a new strategy for large transcatheter implants.
Area of Science:
- Cardiovascular Interventions
- Vascular Access Techniques
- Structural Heart Disease
Background:
- Transcatheter aortic valve replacement (TAVR) is a critical option for high-risk patients with severe aortic stenosis.
- Large introducer sheaths for TAVR pose risks of vascular complications or preclude the procedure.
- Caval-aortic access, a novel technique, has shown promise in animal studies.
Purpose of the Study:
- To describe the first use of caval-aortic access and closure for TAVR in patients lacking alternative access options.
- To evaluate the feasibility and outcomes of this new approach in prohibitive-risk patients.
Main Methods:
- Single-center retrospective review of procedural and 30-day outcomes.
- Nineteen prohibitive-risk patients underwent TAVR via caval-aortic access.
- Caval-aortic access involved percutaneous entry into the abdominal aorta via the inferior vena cava.
Main Results:
- Successful caval-aortic access and tract closure in all 19 patients.
- Successful TAVR in 17 patients (89%).
- Six patients (32%) experienced modified VARC-2 major vascular complications, with 2 requiring intervention. Most patients (79%) required blood transfusion. No deaths were attributed to caval-aortic access. Complete closure of the aorto-caval tract was achieved in 94% of patients by one week post-procedure.
Conclusions:
- Percutaneous transcaval venous access to the aorta is a viable strategy for TAVR in patients otherwise ineligible.
- This technique may provide a new access route for other procedures requiring large transcatheter implants.
- Caval-aortic access offers a potential solution for challenging vascular access in structural heart interventions.
Objectives:
This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava.
Background:
TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals.
Methods:
We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access.
Results:
Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract.
Conclusions:
Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.
