Alternate accesses for transcatheter aortic valve replacement: A network meta-analysis

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Medical Technology Assessment

Background:

• Transcatheter aortic valve replacement (TAVR) typically uses transfemoral (TF) access.
• When TF access is contraindicated, alternative strategies like transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) are considered.
• The optimal choice among these alternate TAVR access routes remains a subject of debate.

Purpose of the Study:

• To compare the safety and efficacy of various alternate access strategies for TAVR.
• To identify the best-performing access routes based on patient outcomes.
• To provide evidence to guide the selection of TAVR access when TF is not feasible.

Main Methods:

• A comprehensive literature search identified studies comparing TF, TA, TAo, TC, and TS TAVR approaches.
• Network meta-analysis was employed to pool data from 84 studies involving 26,449 patients.
• Rank scores were calculated to determine the probability of different treatment groups' rankings.

Main Results:

• Compared to TF access, TA and TAo routes showed higher 30-day and long-term mortality.
• Transcarotid (TC) and trans-subclavian (TS) accesses did not significantly differ from TF in 30-day mortality.
• TF access was ranked best for mortality, followed by TC; TC ranked best for stroke, followed by TS. TA access showed higher long-term stroke rates.
• TC and TS approaches demonstrated superior postoperative outcomes compared to other alternate TAVR access methods.

Conclusions:

• Transcarotid (TC) and trans-subclavian (TS) TAVR approaches are associated with better postoperative results than other alternate strategies.
• Transfemoral (TF) access remains the preferred strategy when feasible.
• Further randomized controlled trials are essential to definitively evaluate the safety and efficacy of alternate TAVR access routes.