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Transcarotid access may be viable alternative to transfemoral TAVR
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Transcarotid vascular access appears to be a safe and feasible access route for transcatheter aortic valve replacement for patients with challenging vascular anatomy that precludes transfemoral access.
Researchers for a new study evaluated 96 consecutive patients enrolled in the French Transcarotid TAVR registry. All patients underwent transcarotid TAVR at three participating sites from 2009 to 2013. Before TAVR, patients were screened with contrast angiography or multislice CT; those with small-caliber (≤ 6 mm), heavily calcified, extremely tortuous or stenotic iliofemoral anatomy, or substantial pathology of the descending aorta were considered candidates for transcarotid TAVR.
The mean age of the patients was 79 years, and the mean Society of Thoracic Surgeons predicted mortality risk was 7.1%.
Patients underwent transcarotid TAVR using a standardized procedural technique utilizing the left common carotid artery as the percutaneous access site. The CoreValve (Medtronic) and the Sapien valve (Edwards Lifesciences) were used during the procedures. Patients were assessed for procedural, 30-day and 1-year clinical endpoints, including stroke, mortality, bleeding, vascular complications and composite endpoints.
According to the findings, successful transcarotid access was achieved in all patients. The following procedural complications occurred: transcathether heart valve embolization (n = 3; 3.1%); need for implantation of a second transcatheter heart valve (n = 3; 3.1%); and cardiac tamponade related to left ventricular wire perforation (n = 4; 4.2%).
Four cases (4.2%) of both major bleeding and major vascular complications occurred; neither of these events involved the carotid vascular access site. Conversion to surgical AVR was not required for any patient. Twenty patients (21.5%) experienced post-implantation aortic regurgitation that was deemed more than mild, according to the results.
Three (3.1%) procedural deaths occurred; one was related to left main coronary artery occlusion and two were related to cardiac tamponade. An additional three deaths occurred at 30 days, due to aspiration pneumonia/multiorgan failure, spontaneously occurring ventricular fibrillation and gastrointestinal hemorrhage. These contributed to a 30-day mortality rate of 6.3%. The mortality rate at 1 year was 16.7%.
Three (3.1%) cases of Valve Academic Research Consortium (VARC)-defined transient ischemic attack were observed. Two TIAs were observe during the immediate postoperative period and one occurred on postoperative day 1. The TIAs were located ipsilateral (n = 1) or contralateral (n = 2) to the carotid vascular access site. None of these cases revealed new ischemic lesions on neuroimaging, and none met the criteria for stroke. Three further cases of TIA were seen at 30 days (one ipsilateral, two contralateral), resulting in an overall event rate of 6.3%. During long-term follow-up, two additional neurological events were reported: an ischemic stroke causing aphasia and visual field deficiencies at day 51, and a hemorrhagic stroke on day 409.
“The results of this study suggest that transcarotid TAVR should be considered a reasonable vascular access route in patients who are not suitable for a transfemoral approach,” the researchers wrote. “Indeed, this technique may have specific advantages over the more invasive transapical or transaortic strategies in certain patient cohorts. Larger series with extended follow-up are required to definitively prove the safety and efficacy of this technique.” – by Jennifer Byrne
Disclosure: Several researchers report financial ties with Edwards Lifesciences and Medtronic. Please see the full study for a list of the researchers’ relevant financial disclosures.
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