At present, the transfemoral access (TFA) is the preferred approach when it comes to transcatheter aortic valve replacement (TAVR). However, 5 to10% of PAD patients present tortuous iliac anatomy and calcification, aortic aneurysms or prior peripheral intervention, which makes it impossible.
There are several alternatives to approach these patients: 1) TFA associated to peripheral PCI stenting and/or intravascular lithotripsy; 2) Transthoracic approach (TTA): including the transapical and transaortic; 3) non-thoracic transalternative approach (TAA): including transaxillary, transcarotid, transubclavian and transcaval. The safety and efficacy of these alternative approaches to TAVR are unknown.
The aim of this multicenter registry was to assess the outcomes of alternative approaches to TAVR in patients with peripheral artery disease (PAD). Also, each strategy was examined according to PAD extension and severity, using the Hostile score (risk assessment score).
Primary end point was major adverse events rate (MAE) at 30 days, defined as a composite of all-cause mortality, stroke, or transient ischemic attack (TIA), or major access site major vascular complications. Secondary end points included primary end point components at 30 days and one year plus cardiac mortality, AMI, and bleeding.
1707 patients were included: 37.6% was treated with TTA, 30.3% with TFA, and 32% with TAA (mostly transaxillary). Among the TFA group, nearly 65% was treated with PCI alone, while the remaining 35% received intravascular lithotripsy prior TAVR. In the TTA group, the transapical approach was the most frequently used. Mean age was 80 and patients were mostly men. STS score was 5.3 -5.9.
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As regards the primary end point, MAE rate at 30 days was 37.9% for the TTA group, 23% for the TFA and 23.9% for the TAA (P>0.0001). This was due mainly because of differences in access site major vascular complications. Both TAF and TAA presented lower MAE rate at 30 days vs. TTA. However, the TAA group presented higher rates of stroke and TIA vs. TTA and TFA (P=0.06).
MAE rate at 1year was 44.75 in the TTA group, 29.1% in the TFA and 28.2% in the TAA group (P<0.0001). TAA was associated to lower all-cause mortality when compared against TTA, but presented higher rates of stroke and TIA vs both groups (TFA and TTA). The Hostile score was an independent predictor of all-cause mortality and stroke in the TFA group, but not for TTA or TAA patients. Among patients with low Hostile score (≤ 8.5) the TFA was associated to MAE reduction and mortality vs. TTA and TAA. While in patients with high Hostile score, TFA was associated to higher rate of stroke vs. TTA, but similar rate to TAA.
Conclusion
In PAD patients undergoing TAVR, TTA was associated to higher MAE rate vs TFA and TAA at 30 days and 1 year, at the expense of access site major vascular complications. At 1 year, TAA was associated to higher risk of stroke and TIA vs. the rest.
In patients with low Hostile score, TFA was the optimal approach for TAVR, showing reduced MAE rate and 1-year mortality vs TTA and lower stroke and TIA rate vs. TAA. Further study is required to assess the optimal approach to patients with high Hostile score.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Vascular Access in Patients With Peripheral Arterial Disease Undergoing TAVR The Hostile Registry.
Reference: Tullio Palmerini, MD et al J Am Coll Cardiol Intv 2023;16:396–411.