Transcaval Access and Closure Best Practices

• Type of Material: Article
• Authors: Robert J. Lederman, National Institutes of Health; Adam Greenbaum, Emory University; Jaffar M. Khan, National Institutes of Health; Christopher G. Bruce, National Institutes of Health; Vasilis Babaliaros, Emory University; Toby Rogers, National Institutes of Health
• Language: English
• Date: 2023-02-27
• Publisher: JACC
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: Published by Elsevier on behalf of the American College of Cardiology Foundation.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jcin.2022.12.005
• Title of Journal or Parent Work: JACC: Cardiovascular Interventions
• Volume: 16
• Issue: 4
• Start Page: 371
• End Page: 395
• Grant/Funding Information: This work was supported by the Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health (grant Z01-HL006040) (to Dr Lederman). All authors are coinventors of patents, assigned to the National Institutes of Health, for transcaval- or electrosurgery-related devices. Drs Greenbaum and Babaliaros have received institutional research support from Abbott Vascular, Ancora Heart, Edwards Lifesciences, Gore Medical, JenaValve, Medtronic, Polares Medical, Transmural Systems, and 4C Medical; have received consulting fees from Abbott Vascular, Edwards Lifesciences, and Medtronic; and have equity interest in Transmural Systems. Dr Rogers is a consultant and physician proctor for Edwards Lifesciences, Medtronic, and Boston Scientific; is an advisory board member for Medtronic; and holds equity interest in Transmural Systems. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
• Keywords: vascular access; TEVAR; Arteries; Endovascular Aneurysm Repair; TAVR; Treatment Outcome; Aorta, Abdominal; Humans; Patient Selection; nonfemoral access; mechanical circulatory support; transcaval
• Research Categories: Health Sciences, Health Care Management; Health Sciences, Medicine and Surgery

Abstract

Transcaval aortic access is a versatile electrosurgical technique for large-bore arterial access through the wall of the abdominal aorta from the adjoining inferior vena cava. Although counterintuitive, its relative safety derives from the recognition that interstitial hydraulic pressure exceeds venous pressure, so arterial bleeding harmlessly decompresses into the nearby caval venous hole. Transcaval access has been performed in thousands of patients for transcatheter aortic valve replacement and endovascular thoracic aneurysm repair and to avoid limb ischemia in percutaneous mechanical circulatory support. Transcaval access may have value compared with transaxillary or subclavian access and with surgical transcarotid access when standard transfemoral access is not optimal. The dissemination of transcaval access and closure techniques has been hampered by the unavailability of commercially marketed devices. This state-of-the-art review details exemplary transcaval technique, patient selection, computed tomographic planning, step-by-step access and closure, management of complications, and procedural troubleshooting in special situations. These contemporary best practices can help operators gain or maintain proficiency.