Evolution of Alternative-access Transcatheter Aortic Valve Replacement.

Area of Science:

• Cardiology
• Interventional Cardiology
• Vascular Surgery

Background:

• Transfemoral access is standard for transcatheter aortic valve replacement (TAVR), but alternative access is needed for some patients.
• This study examines the evolution and outcomes of alternative-access TAVR at Cleveland Clinic from 2006 to 2019.

Purpose of the Study:

• To describe the trends and clinical outcomes of alternative access strategies for TAVR.
• To compare the safety and efficacy of different alternative access routes, including transaxillary, transfemoral, and transthoracic approaches.

Main Methods:

• Analysis of 2446 TAVR patients from January 2006 to January 2019, with 414 (17%) undergoing alternative access.
• Alternative access routes included transapical, transaortic, transaxillary, transcarotid, transiliac, and transcaval.
• Propensity-matched comparisons were performed between transfemoral and transaxillary approaches since 2012.

Main Results:

• The transaxillary approach has become the favored alternative access route, shifting from transapical and transaortic.
• While major vascular injuries were higher with alternative access versus transfemoral (2.9% vs 1.3%), minor vascular injuries were lower (3.1% vs 9.8%).
• Transaxillary access showed better operative outcomes than transthoracic approaches, with fewer transfusions, less ventilation, and shorter hospital stays. Survival and major morbidity were similar between transfemoral and transaxillary approaches in matched comparisons.

Conclusions:

• The transaxillary approach is the preferred alternative access strategy for TAVR.
• It offers improved operative outcomes compared to transthoracic approaches and comparable results to transfemoral access.
• No brachial plexus injuries were observed with transaxillary access.