Transcaval Versus Transaxillary TAVR in Contemporary Practice A Propensity-Weighted Analysis

• Type of Material: Article
• Authors: Robert Lederman, Emory University; Vasilis Babaliaros, Emory University; John Lisko, Emory University; Toby Rogers, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda; Paul Mahoney, The Sentara Heart Center; Jason R Foerst, Virginia Tech; Jeremiah P Depta, Rochester Reg Hlth; Kamran I Muhammad, Oklahoma Heart Institute, Tulsa; James M McCabe, University of Washington; Andrei Pop, AMITA Health Alexian Brothers Medical Center, Elk Grove Village, Illinois; Jaffar M Khan, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda; Christopher G Bruce, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda; Giorgio A Medranda, MedStar Washington Hospital Center; Jane W Wei, Emory University; Jose N Binongo, Emory University; Adam Greenbaum, Emory University
• Language: English
• Date: 2022-05-02
• Publisher: ELSEVIER SCIENCE INC
• 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-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jcin.2022.03.014
• Title of Journal or Parent Work: JACC-CARDIOVASCULAR INTERVENTIONS
• Volume: 15
• Issue: 9
• Start Page: 965
• End Page: 975
• Keywords: Cardiac & Cardiovascular Systems; TRANSCATHETER; nonfemoral access; alternative access; subclavian access; percutaneous access; SAFETY; transaxillary access; transcaval access; TVT REGISTRY; Science & Technology; OUTCOMES; AORTIC-VALVE-REPLACEMENT; Cardiovascular System & Cardiology; SUBCLAVIAN/AXILLARY ACCESS; Life Sciences & Biomedicine; IMPLANTATION

Abstract

Objectives: The aim of this study was to compare transcaval and transaxillary artery access for transcatheter aortic valve replacement (TAVR) at experienced medical centers in contemporary practice. Background: There are no systematic comparisons of transcaval and transaxillary TAVR access routes. Methods: Eight experienced centers contributed local data collected for the STS/ACC TVT Registry (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry) between 2017 and 2020. Outcomes after transcaval and axillary/subclavian (transaxillary) access were adjusted for baseline imbalances using doubly robust (inverse propensity weighting plus regression) estimation and compared. Results: Transcaval access was used in 238 procedures and transaxillary access in 106; for comparison, transfemoral access was used in 7,132 procedures. Risk profiles were higher among patients selected for nonfemoral access but similar among patients requiring transcaval and transaxillary access. Stroke and transient ischemic attack were 5-fold less common after transcaval than transaxillary access (2.5% vs 13.2%; OR: 0.20; 95% CI: 0.06-0.72; P = 0.014) compared with transfemoral access (1.7%). Major and life-threatening bleeding (Valve Academic Research Consortium 3 ≥ type 2) were comparable (10.0% vs 13.2%; OR: 0.66; 95% CI: 0.26-1.66; P = 0.38) compared with transfemoral access (3.5%), as was blood transfusion (19.3% vs 21.7%; OR: 1.07; 95% CI: 0.49-2.33; P = 0.87) compared with transfemoral access (7.1%). Vascular complications, intensive care unit and hospital length of stay, and survival were similar between transcaval and transaxillary access. More patients were discharged directly home and without stroke or transient ischemic attack after transcaval than transaxillary access (87.8% vs 62.3%; OR: 5.19; 95% CI: 2.45-11.0; P < 0.001) compared with transfemoral access (90.3%). Conclusions: Patients undergoing transcaval TAVR had lower rates of stroke and similar bleeding compared with transaxillary access in a contemporary experience from 8 US centers. Both approaches had more complications than transfemoral access. Transcaval TAVR access may offer an attractive option.