Transcaval Access: Another Alternative to Femoral Access Counterindication

For TAVR eligible patients (transcatheter aortic valve replacement) with femoral access counterindication, a new access site, extra thoracic yet percutaneous, may offer an alternative. This consists of reaching the abdominal aorta through the vena cava.

With this technique the operator enters the abdominal aorta through the vena cava by electrifying a guidewire, advancing a prepositioned aortic snare, and performing conventional TAVR through introducer sheaths. 

Finally, the communication between the cava and the aorta is closed with nitinol cardiac occluders.

This technique was developed to avoid the discomfort and morbidity of established access sites, such as the transthoracic, the transapical and the transaortic.

The primary end point was successful vena cava access and successful occluder implantation (Amplatzer Nitinol Occluder, St. Jude Medical) in absence of death or emergency surgery. This objective was reached in 98 out of the 100 patients treated in 20 different centers between 2014 and 2016.

In one patient, the operator failed to cross the guidewire and then switched to transfemoral TAVR, which complicated with an iliac artery rupture. Another patient received a coated stent instead of the occluder.

There were no periprocedural deaths or emergency surgeries. Observed complications (coronary obstruction, annulus hematoma, pacemaker need) were not associated to access site.

30 day survival rate was 92%, life threatening major bleeding rate (VARC2) was 7% and major vascular complications rate was 13%.

The physiological rationale behind this procedure would be that the venous system pressure is lower than that of the surrounding tissues, which is why the blood will always tend to go from the aorta to the vena cava, and not to the retroperitoneum.

Mean inhospital stay was 4 days (2-6), which is reasonable for this kind of procedure.

These safety findings are vital, taking into account that most centers had no experience in this kind of access.

Conclusion

The transcaval access site allows transcatheter aortic valve replacement in patients with femoral access counterindication who also make bad transthoracic access candidates.

Bleeding and vascular complications were common but acceptable, bearing in mind this cohort was high risk.

Original Title: Transcaval access and closure for transcatheter aortic valve replacement: a prospective investigation.

Reference: Greenbaum AB et al. J Am Coll Cardiol. 2016; Epub ahead of print.

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