Is Transcarotid Access a Safe Option in TAVI?

Transcatheter aortic valve implantation (TAVI) should preferably be conducted via transfemoral access, according to European guideline (in patients ≥75 years) and American guideline (in patients ≥80 years) recommendations. However, in many cases, this approach is not feasible due to occlusion, severe lesions in the femoral or iliac arteries, excessive tortuosity, or aortic disease.

Alternative accesses, such as transthoracic or apical, have shown higher complication rates. Transcarotid access in TAVI (TC TAVI) has been assessed in some studies, which had shown it to be feasible and safe, although we still have limited information about its true benefit or validity as an alternative to surgery.

In this analysis, researchers evaluated 786 patients with severe aortic stenosis: 434 (55.2%) underwent TC TAVI due to inadequate transfemoral access, and the rest underwent surgical aortic valve replacement (SAVR).

The primary endpoint (PEP) was a composite of all-cause mortality, stroke, transient ischemic attack (TIA), and procedure-related rehospitalization (PRR) at 30 days and 12 months.

Since the populations were not comparable — TC TAVI patients were older, had higher STS scores, and more comorbidities —propensity score matching analysis was conducted. It resulted in 182 patients in each group.

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Among them, 38 of subjects were women. Baseline characteristics were as follows: average patient age 74 years; STS mortality score 3.6%, hypertension 90%, diabetes 44%, previous coronary artery disease 44%, peripheral vascular disease 55%, chronic obstructive pulmonary disease (COPD) 24%, impaired renal function 41%, atrial fibrillation 22%, previous cardiothoracic surgery 12%, and 55-% ejection fraction. There were no differences in aortic valve area or initial gradients.

The most commonly used valve in the TC TAVI group was the balloon-expandable type (70%).

At the end of the procedure, TC TAVI patients had a larger valve area (1.84 cm² vs. 1.47 cm²; P <0.001) and a lower gradient (11.4 mmHg vs. 14.7 mmHg; P <0.001), with no differences in ejection fraction. During hospitalization, there were no differences in mortality, stroke, or TIA, but the SAVR group showed higher incidence of bleeding, atrial fibrillation, and renal deterioration, while the TC TAVI group had more cases requiring permanent pacemaker implantation and vascular complications.

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The 30-day PEP was significantly higher in the SAVR group (12.6% vs. 4.3%; hazard ratio [HR] 2.93 [95% confidence interval (CI) 1.45–5.94]), with no differences in mortality, stroke, or TIA, but a higher rate of PRR (6.1% vs. 1.6%; P = 0.028).

At 12 months, there were no significant differences between groups neither in the PEP (12.7% vs. 19.7%; HR 1.64 [95% CI 0.99–2.74]; P = 0.059) nor in mortality, stroke, TIA, or procedure-related rehospitalization.

Conclusion

Transcarotid access in TAVI was associated with better clinical outcomes at 30 days compared to surgery, although there were no significant differences in mortality, stroke, or rehospitalization at the one-year follow-up. These findings suggest that TAVI via transcarotid access could be a valid alternative to surgery in patients who are not candidates for transfemoral access.

Original Title: Transcarotid Versus Surgical Aortic Valve Replacement for the Treatment of Severe Aortic Stenosis. 

Reference: Juan Hernando del Portillo, et al. Circ Cardiovasc Interv. 2025;18:e014928. DOI: 10.1161/CIRCINTERVENTIONS.124.014928.