TAVR: If Not Transfemoral, We Should Consider Transcaval Access

Transcatheter aortic valve replacement (TAVR) through transfemoral access has already proven its great benefits, but this access cannot be used in certain patients, and alternative accesses need to be considered for such cases.

Los dispositivos Amplatzer y Figulla demuestran ser seguros para el cierre percutáneo del foramen oval permeable

One of the most commonly used accesses is the transaxillary or transubclavian access (AX), which, however, is associated with more complications (especially stroke). Another alternative—one that is scarcely used—is the transcaval access (TC), although very little information is available in relation to it.

While much less frequently, carotid, apical and transaortic accesses have been used; at present, they are practically not used anymore.

The analysis included 7476 TAVR procedures performed in 8 high-volume sites. Of these, 7132 (95.4%) were performed by transfemoral access (FA), 238 (3.2%) by TC, and 106 (1.4%) by AX.

The primary endpoint was a composite of bleeding and stroke.

The mean age was 77 years. There were more men in the FA and AX groups, but more women in the TC group.

The surgical risk was higher for those in the AX and TC groups.

TC access required more contrast and fluoroscopy time.

The primary endpoint was more frequent in non-transfemoral accesses.

The presence of stroke or transient ischemic attack (TIA) was 5 times less frequent in TC than in AX (2.5% vs. 13.2%; odds ratio [OR]: 0.20; 95% confidence interval [CI]: 0.06-0.72; p = 0.014) compared with that for FA, which was 1.7%.

Major bleeding rates were similar between TC and AX accesses (10.0% vs. 13.2%; OR: 0.66; 95% CI: 0.26-1.66; p = 0.38), but higher for FA, which was 3.5%. The same happened with the need for transfusion (19.3% vs. 21.7%; OR: 1.07; 95% CI: 0.49-2.33; p = 0.87) compared with FA (7.1%).

Vascular complications, intensive care stay, and survival were similar between non-transfemoral accesses.

Discharge directly to home without stroke or TIA was superior in the TC group compared with the AX group (87.8% vs. 62.3%; OR: 5.19; 95% CI: 2.45-11.0; p < 0.001). In the FA group, it was 90.3%.

Conclusion

Patients who underwent TAVR by transcaval access had a lower stroke rate, but a similar bleeding rate, compared with those who underwent TAVR by transaxillary access in this analysis from 8 sites in the United States. Both accesses present more complications than transfemoral access. Transcaval access may offer an attractive alternative.