Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral transcatheter aortic valve implantation: A propensity-matched analysis

Five-year outcomes of transcarotid transcatheter aortic valve replacement

BACKGROUND

Transcarotid transcatheter aortic valve replacement (TC-TAVR) has emerged as an alternative access route for transcatheter aortic valve replacement (TAVR). However, scarce data exist on long-term outcomes following TC-TAVR. This study aimed to evaluate clinical outcomes at 5 years after TC-TAVR.

METHODS

A total of 110 consecutive patients who underwent TC-TAVR were included. Baseline, procedural, and follow-up data were collected prospectively in a dedicated database. The primary endpoint was the incidence of a composite outcome of all-cause mortality, stroke, and repeat hospitalization at 5-year follow-up. Echocardiography results, New York Heart Association (NYHA) class, and quality of life (QoL) as assessed with the EuroQol visual analog scale (EQ-VAS) were examined over the 5-year follow-up.

RESULTS

The median patient age was 77 years (interquartile range [IQR], 72-82.2 years), 42.3% were women, and the median Society of Thoracic Surgeons (STS) risk score was 5.02% (IQR, 3.4%-7.5%). The incidence of the composite primary endpoint was 54.5%. Death from any cause occurred in 45.6% of patients (11.9 per 100 patient-years); stroke in 8.2% (1.9 per 100 patient-years); disabling stroke in 2.7% (0.7 per 100 patient-years); and rehospitalization in 27.2%. The improvements in valve hemodynamics, NYHA class, and EQ-VAS following the procedure persisted at 5-year follow-up (P < .001). The incidence of bioprosthetic valve failure was 0.9%.

CONCLUSIONS

About half of the moderate-to high-risk patients undergoing TC-TAVR survived with no major cardiovascular events at the 5-year follow-up. The yearly incidence of stroke events was low, and early improvements in valve hemodynamics, functional status, and QoL persisted at 5 years. These results suggest the long-term safety and efficacy of TC-TAVR and would support this approach as an alternative to surgery in non-transfemoral candidates.

Trans-femoral versus trans-carotid access for transcatheter aortic valve replacement: an updated systematic review and meta-analysis

Aim: This meta-analysis aims to shed light on any primacy the trans-carotid (TC-TAVR) access may have over the trans-femoral access (TF-TAVR) for those undergoing transcatheter aortic valve replacement (TAVR). Methods: PubMed/MEDLINE and Cochrane Library were searched, from inception to March 2023 retrieving seven adjusted studies with a total of 6609 patients, of which 5048 underwent TF-TAVR while 1561 underwent TC-TAVR. Results: No divergence in risk of mortality, major bleeding or stroke/transient ischemic attack in TC-TAVR when compared with TF-TAVR was found. In TC-TAVR, the risk of vascular complications was low (OR: 0.51, 95% CI: 0.32-0.83, p = 0.003) as compared with TF-TAVR. Conclusion: As of this analysis, the viability of TC-TAVR as first alternative to TF-TAVR is plausible.

Transcarotid versus trans-axillary/subclavian transcatheter aortic valve replacement (TAVR): A systematic review and meta-analysis

BACKGROUND

Transcatheter Aortic Valve Replacement (TAVR) is the treatment of choice in patients with severe aortic stenosis. Transcarotid (TCa) or Trans-axillary/subclavian (TAx/Sc) are safer and less invasive non-femoral approaches, where transfemoral access is difficult or impossible to obtain.

METHODS

This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023482842). This meta-analysis was performed to compare the safety of the transcarotid and trans-axillary/subclavian approach for TAVR including studies from inception to October 2023.

RESULTS

Seven studies with a total of 6227 patients were included in the analysis (TCa: 2566; TAx/Sc: 3661). Transcarotid TAVR approach had a favorable trend for composite of stroke and all-cause mortality (OR 0.79, CI 0.60-1.04), all-cause mortality, stroke, major vascular complication, and new requirement of permanent pacemaker though those were statistically insignificant. On sub-analysis of the results of the studies based on the territory (USA vs French), composite outcome of all cause mortality, stroke and major bleeding (OR 0.54, CI 0.54-0.81), composite of stroke and all cause mortality (OR 0.64, CI 0.50-0.81), and stroke/TIA (OR 0.53, CI 0.39-0.73) showed lower odds of occurrence among patient managed with TCa approach in the American cohort.

CONCLUSION

Overall, transcarotid approach had favorable though statistically insignificant odds for composite (stroke and all-cause mortality) and individual outcomes (stroke, all-cause mortality, etc.). There are significant variations in observed outcomes based on study's geographic location. Large prospective randomized clinical trials comparing the two approaches with representative samples are necessary to guide the clinicians in choosing among these approaches.

Vascular access for transcatheter aortic valve replacement: A network meta-analysis

BACKGROUND

The choice of an alternative access for transcatheter aortic valve replacement (TAVR) remains controversial when transfemoral (TF) access is not feasible.

METHODS

We conducted a network meta-analysis to compare the outcomes of TAVR via various peripheral vascular accesses. MEDLINE and EMBASE were searched through July 2022 to identify studies that investigated outcomes in patients who underwent TAVR via TF, trans-subclavian (Tsc), transcarotid (TC), or transcaval (Tcav) access. A network meta-analysis was conducted via random-effects model. Outcomes of interest were major or life-threatening bleeding, stroke, major vascular complication, and 30-day mortality.

RESULTS

No randomized trial was identified. Our analysis included 33 observational studies that enrolled a total of 43,455 patients who underwent TAVR via TF (n = 36,202), Tsc (n = 3869), TC (n = 3066), or Tcav (n = 318) access. The risk of major or life-threatening bleeding was higher via Tsc compared with TF [odds ratio (OR); 95 % confidence interval (CI) =1.51 (1.03-2.23), p = 0.034]. The risk of stroke was higher via Tsc compared with TF and Tcav [OR (95 % CI) =2.00 (1.14-3.52), p = 0.018, OR (95 % CI) =2.43 (1.03-5.74), p = 0.044, respectively]. The risk of major vascular complications was lower via TC compared with Tsc, and Tcav and higher with Tcav compared with TF and Tsc. 30-day mortality was higher via Tsc compared with TF. Tsc was associated with higher risk of major or life-threatening bleeding compared with TF, and higher risk of stroke compared to TF and Tcav. Tcav had the highest risk of major vascular complications.

CONCLUSION

In patients who underwent TF, Tsc, TC, or Tcav TAVR, Tsc had a higher rate of stroke compared to TF and Tcav, and major or life-threatening bleeding compared to TF. The rate of major vascular complications in Tcav was the highest among the four approaches.

Comparison of Alternative Peripheral and Transfemoral Approaches for Transcatheter Aortic Valve Replacement: A Meta-Analysis of Propensity-Matched Studies

Background. Transfemoral (TF) access is the gold standard for transcatheter aortic valve replacement (TAVR). Alternative peripheral (AP) artery access such as the carotid or axillary artery is considered when the feasibility of femoral access is in doubt. The outcomes comparison of these 2 approaches is unclear due to limited sample sizes in prior studies. Our aim is to compare the clinical outcomes of TF- and AP-TAVR by conducting a meta-analysis of propensity-matched studies. Methods. The PubMed, EMBASE, and Cochrane Library databases from inception up to and including February 2022 were searched by 3 separate researchers to identify articles reporting propensity-matched, comparative data on TF vs. AP-TAVR. Clinical outcomes were extracted from the articles and pooled for analysis. Results. Seven prior studies, including 9,004 patients, were included in our study, with 6,729 in the TF group and 2,275 in the AP group. In all studies, the baseline characteristics of the patients were highly propensity-matched with the full Newcastle-Ottawa scale. Meta-analysis revealed higher in-hospital/30-day mortality (3.3% vs. 4.4%; OR 0.69; 95% CI (0.51, 0.94); $P=0.02$ ) as well as the incidence of stroke (1.9% vs. 3.5%; OR 0.60; 95% CI (0.43, 0.84); $P=0.003$ ) for the AP group. There were no significant differences in the incidence of major vascular complications, pacemaker implantation, bleeding, or acute kidney injury. Conclusions. Our meta-analysis of propensity-matched studies showed AP-TAVR contains an additional 1.1% risk of early mortality and an additional 1.6% risk of stroke compared to TF-TAVR. These risks should be considered when deciding on access.

Transcarotid Access Versus Transfemoral Access for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Background: The transfemoral (TF) route is the gold-standard access for transcatheter aortic valve replacement (TAVR). In 10–15% of patients, alternative accesses are needed, such as the transcarotid (TC) access. We performed a meta-analysis to compare 30-day mortality and complications between TC-TAVR and TF-TAVR.

Methods: We searched PubMed/MEDLINE and EMBASE from inception to January 2021 to identify articles comparing TC-TAVR and TF-TAVR. Patients' baseline characteristics, procedural outcomes, and clinical 30-day outcomes were extracted.

Results: We identified 9 studies, among which 2 used propensity-score matching, including 1,374 TC patients and 3,706 TF patients. TC-TAVR was associated with significantly higher EuroSCORE II and Logistic EuroSCORE values (respectively 8.0 ± 6.7 vs. 6.3 ± 5.4, p = 0.002 and 20.8 ± 14.2% vs. 20.0 ± 13.4%, p = 0.04), a higher prevalence of peripheral artery disease (52.6 vs. 32.8%, p = 0.001), previous cardiac surgery (26.3 vs. 22.4%, p = 0.008) and coronary artery disease (64.6 vs. 60.5%, p = 0.020). The pooled results found TC-TAVR to be associated with a significantly higher 30-day mortality risk (RR, 1.41, 95% CI, 1.02–1.96, p = 0.040), and a lower rate of 30-day major vascular complications (RR, 0.48, 95% CI, 0.25–0.92, p = 0.030). No significant difference was found regarding permanent pacemaker implantation, major bleeding and acute kidney injury. A subgroup analysis of the two propensity-score matched studies found a statistically increased risk of 30-day neurovascular complications (RR, 1.61, 95% CI, 1.02–2.55, p = 0.040).

Conclusion: Compared with TF-TAVR, TC-TAVR was associated with an increased risk of 30-day mortality, likely related to a higher surgical risk and comorbidity burden, and with an increased risk of 30-day neurovascular complications. Careful preprocedural patient selection and close periprocedural neurological monitoring are paramount.

Long-Term Clinical Outcomes and Carotid Ultrasound Follow-Up of Transcarotid TAVI. Prospective Single-Center Registry

This study aimed to prospectively evaluate the safety and long-term clinical outcomes of cerebral-oximetry-guided transcarotid transcatheter aortic valve implantation (TC-TAVI) with systematic follow-up with carotid ultrasound. Thirty-three TCTAVI procedures were performed in our center from 2017 to 2019. Our analysis includes in-hospital outcomes and long-term follow-up data on mortality, echocardiographic parameters, carotid Doppler ultrasound, and VARC-2 defined clinical events. Intraoperatively, one patient died, and one had a transient ischemic attack (TIA). The following events occurred in-hospital postoperatively: myocardial infarction (3.0%), cardiac tamponade (3.0%), new-onset atrial fibrillation (6.3%), need for temporary pacing (27.3%) and need for pacemaker implantation (15%). The mean follow-up was 19.5 ± 9.52 months. In the long-term follow-up, the two-year survival rate was 83% ± 14. The echocardiographic parameters did not differ significantly from the postprocedural values, and the ultrasound did not show any cases of significant vessel narrowing. The mean peak systolic velocity (PSV) was 71.6 cm/s in the left common carotid artery and 70.6 cm/s in the right common carotid artery. In conclusion, cerebral oximetry-guided TC access is safe, has a favorable long-term outcome, and does not increase the risk of plaque formation in the carotid artery. In a carefully selected group of patients, it might be considered as a first-choice alternative to TF access.

Current Trends in TAVI Access

The optimal approach for Transcatheter aortic valve implantation (TAVI) is the transfemoral access but alternative TAVI approaches offer the possibility of valve replacement in patients who are not eligible to the transfemoral route. This review paper intends to compare the current available alternative approaches for TAVI in terms of their safety and efficacy, based on the current literature. The transapical, transaortic, transsubclavian, transcarotid, transcaval and suprasternal approaches have been analyzed. The choice of the alternative approach dependents on local Heart Team expertise, patient specific characteristics, access specific characteristics and the need or not for general anesthesia. More studies are needed to investigate the impact of each individual approach on long-term outcomes.

Femoral Versus Nonfemoral Subclavian/Carotid Arterial Access Route for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Background

Some concerns remain regarding the safety of transcarotid and transsubclavian approaches for transcatheter aortic valve replacement. We aimed to compare the risk of 30‐day complications and death in transcarotid/transsubclavian versus transfemoral transcatheter aortic valve replacement recipients.

Methods and Results

Data from 20 studies, including 79 426 patients (16 studies) and 3992 patients (4 studies) for the evaluation of the unadjusted and adjusted impact of the arterial approach were sourced, respectively. The use of a transcarotid/transsubclavian approach was associated with an increased risk of stroke when using unadjusted data (risk ratio [RR], 2.28; 95% CI, 1.90–2.72) as well as adjusted data (odds ratio [OR], 1.53; 95% CI, 1.05–2.22). The pooled results deriving from unadjusted data showed an increased risk of 30‐day death (RR, 1.46; 95% CI, 1.22–1.74) and bleeding (RR, 1.53; 95% CI, 1.18–1.97) in patients receiving transcatheter aortic valve replacement through a transcarotid/transsubclavian access (compared with the transfemoral group), but the associations between the arterial access and death (OR, 1.22; 95% CI, 0.89–1.69), bleeding (OR, 1.05; 95% CI, 0.68–1.61) were no longer significant when using adjusted data. No significant effect of the arterial access on vascular complication was observed in unadjusted (RR, 0.84; 95% CI, 0.66–1.06) and adjusted (OR, 0.79; 95% CI, 0.53–1.17) analyses.

Conclusions

Transcarotid and transsubclavian approaches for transcatheter aortic valve replacement were associated with an increased risk of stroke compared with the transfemoral approach. However, these nonfemoral arterial alternative accesses were not associated with an increased risk of 30‐day death, bleeding, or vascular complication when taking into account the confounding factors.