TAVR: Should Transradial Approach be the Second Access Site?

Courtesy of Dr. Carlos Fava.

One of the major challenges we interventional cardiologists still face is access management. Reduced device diameter and improved transcatheter closure, together with increased operator experience, have significantly reduced vascular complications. However, we shouldn’t lose sight of the secondary access, usually transfemoral, generally used in case of primary access site related complications. 

Here is where the transradial approach (which has shown good results in coronary territory) rises as a viable alternative, since the scarce information currently available would make the secondary access responsible for 25% of vascular complications. 

The study looked at 4949 patients undergoing TAVR between 2007 and 2018. 4016 (81.1%) had transfemoral secondary access, while the remaining 933 (18.9%) had transradial secondary access.

The groups were similar, mean age was 81, but the transfemoral group had more women and higher STS score (4.9% vs. 4.7% p=0.032). The transradial group had more presence of coronary artery disease and CABG. 

Read also: ACC 2019 | SAFARI: Unexpectedly, Radial Approach Offers No Benefits In STEMI.

First generation valves were more often used in the transradial group, with no difference in procedural success. 

Global vascular complications (VC) were 16.9% (major VC, 5.7%). The total rate of VC related to the secondary access was 3.5% (major VC, 1.3%).

The rate of VC related to the secondary access was higher in the transfemoral group (4.1% vs. 0.9% p<0.001). In addition, the rate of major VC was also higher (1.6% vs. 0% p>0.01).

Read also: Are 7 Fr Dedicated Transradial Introducers Safe?

In the propensity score-matched population, VC related to the secondary access remained higher in the transfemoral group (4.7% versus 0.9%, P<0.001, and major VC 1.8% versus 0%, P<0.001).

At 30 days, the transfemoral secondary access group presented higher rates of stroke (3.1% vs. 1.6% p=0.043), acute kidney failure (9.9 vs. 5.7 p<0.001) and mortality (4% vs. 2.4% p=0.047).

Conclusion

The use of transradial approach in TAVR was associated with reduced rates of vascular complications and bleeding, and had better results at 30 days. Future randomized studies are justified. 

Courtesy of Dr. Carlos Fava.

Original Title: Comparison of Transfemoral Versus Transradial Secondary Access in Transcatheter Aortic Valve Replacement.

Reference: Lucía Junquera, et al. Circ Cardiovasc Interv. 2020;13:e008609. DOI: 10.1161/CIRCINTERVENTIONS.119.008609.

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