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McGrath D, Lee H, Sun C, Kawabori M, Zhan Y. Right transaxillary transcatheter aortic valve replacement is comparable to left despite challenges. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02015-z. [PMID: 38460099 DOI: 10.1007/s11748-024-02015-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES Transaxillary access is the most popular alternative to transfemoral transcatheter aortic valve replacement. Although left transaxillary access is generally preferred, right transaxillary transcatheter aortic valve replacement could be challenging because of the opposing axillary artery and aortic curvatures, which may warrant procedural modifications to improve alignment. Our aim is to compare our single center's outcomes for left and right transaxillary access groups and to evaluate procedural modifications for facilitating right transaxillary transcatheter aortic valve replacement. METHODS Patient characteristics and outcomes were compared for consecutive left or right axillary TAVRs performed from 6/2016 to 6/2022 with SAPIEN 3. The effects of our previously reported "flip-n-flex" technique on procedural efficiency and new conduction disturbances were subanalyzed in the right axillary group. RESULTS Right and left transaxillary transcatheter aortic valve replacement were performed in 25 (18 with the "flip-n-flex" technique) and 26 patients, respectively. There were no significant differences between patient characteristics or outcomes. Right axillary subanalysis showed the "flip-n-flex" technique group had significantly shorter fluoroscopy times (21.2 ± 6.2 vs 29.6 ± 12.4 min, p = 0.03) and a trend towards less permanent pacemaker implantation (6.3% vs. 42.9%, p = 0.07) compared to the group without "flip-n-flex". CONCLUSIONS In our study, despite anatomical challenges, right transaxillary transcatheter aortic valve replacement is comparable to left access. The "flip-n-flex" technique advances right transaxillary as an appealing access for patients with few options.
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Affiliation(s)
| | - Hansuh Lee
- Tufts University School of Medicine, Boston, MA, USA
| | - Charley Sun
- Tufts University School of Medicine, Boston, MA, USA
| | - Masashi Kawabori
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Yong Zhan
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA.
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2
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Linder M, Grundmann D, Kellner C, Demal T, Waldschmidt L, Bhadra O, Ludwig S, Voigtländer L, von der Heide I, Nebel N, Hannen L, Schirmer J, Reichenspurner H, Blankenberg S, Conradi L, Schofer N, Schäfer A, Seiffert M. Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation in Patients with Severe Iliofemoral Calcifications: Expanding Transfemoral Indications. J Clin Med 2024; 13:1480. [PMID: 38592323 PMCID: PMC10932192 DOI: 10.3390/jcm13051480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Transfemoral transcatheter aortic valve implantation (TAVI) has become the standard treatment for most patients with severe symptomatic aortic stenosis. Intravascular lithotripsy may facilitate transfemoral TAVI (IVL-TAVI) even in patients with severely calcified iliofemoral disease. We assessed technical aspects and clinical outcomes of this novel approach compared to alternative transaxillary access (TAX-TAVI). (2) Methods: IVL-TAVI was performed for severe iliofemoral calcifications precluding standard transfemoral access in 30 patients from 2019 to 2022 at a single academic heart center. IVL was performed as part of the TAVI procedure in all cases. Results were compared to a control group of 44 TAX-TAVI procedures performed for the same indication from 2016 to 2021. The safety outcome was a composite of all-cause death, stroke, access-related bleeding ≥ type 2 within 24 h and major vascular access site complications at 30 days. The efficacy outcome was defined as a technical success according to VARC-3. (3) Results: Median age was 78.2 [74.3, 82.6] years, 45.9% were female and mean STS-PROM was 3.6% [2.3, 6.0]. Iliofemoral calcifications were more severe in the IVL-TAVI vs. TAX-TAVI groups (lesion length: 63.0 mm [48.6, 80.3] vs. 48.5 mm [33.1, 68.8]; p = 0.043, severe calcification at target lesion: 90.0% vs. 68.2%; p = 0.047, and median arc calcification 360.0° [297.5, 360.0] vs. 360.0° [180.0, 360.0]; p = 0.033). Technical success was achieved in 93.3% vs. 81.8% (p = 0.187) in IVL- and TAX-TAVI and the safety outcome occurred in 10.0% vs. 31.8% in IVL- and TAX-TAVI (p = 0.047), respectively. (4) Conclusions: IVL-assisted transfemoral TAVI was feasible and safe with favorable outcomes compared to TAX-TAVI. IVL may further expand the number of patients eligible for transfemoral TAVI and may help overcome limitations of an alternative access.
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Affiliation(s)
- Matthias Linder
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Department of Cardiology, Regio Kliniken Pinneberg GmbH, Fahltskamp 74, 25421 Pinneberg, Germany
| | - David Grundmann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, 24105 Kiel, Germany
| | - Lara Waldschmidt
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Oliver Bhadra
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Lisa Voigtländer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, 24105 Kiel, Germany
| | - Ina von der Heide
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Nicole Nebel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Laura Hannen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Johannes Schirmer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, 24105 Kiel, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Niklas Schofer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Andreas Schäfer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, 24105 Kiel, Germany
- Department of Cardiology and Angiology, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
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3
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Al Adas Z, Uceda D, Mazur A, Zehner K, Agrusa CJ, Wang G, Schneider DB. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg 2024; 79:487-496. [PMID: 37918698 DOI: 10.1016/j.jvs.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/20/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. CONCLUSIONS Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.
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Affiliation(s)
- Ziad Al Adas
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Domingo Uceda
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alexa Mazur
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kiera Zehner
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill, Cornell Medical Center, New York, NY
| | - Grace Wang
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Darren B Schneider
- Division of Vascular and Endovascular Therapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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4
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De Marzo V, Zimarino M. The value of transaxillary access for TAVI. Int J Cardiol 2024; 397:131448. [PMID: 37863435 DOI: 10.1016/j.ijcard.2023.131448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/15/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Vincenzo De Marzo
- Cardiology Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Marco Zimarino
- Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy; Department of Neuroscience, Imaging, and Clinical Sciences, University of Chieti-Pescara, Italy.
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5
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Antiochos P, Kirsch M, Monney P, Tzimas G, Meier D, Fournier S, Ferlay C, Nowacka A, Rancati V, Abellan C, Skalidis I, Muller O, Lu H. Transcaval versus Supra-Aortic Vascular Accesses for Transcatheter Aortic Valve Replacement: A Systematic Review with Meta-Analysis. J Clin Med 2024; 13:455. [PMID: 38256589 PMCID: PMC10816274 DOI: 10.3390/jcm13020455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
A growing body of evidence suggests that extrathoracic vascular accesses for transcatheter aortic valve replacement (TAVR) yield favorable outcomes and can be considered as primary alternatives when the gold-standard transfemoral access is contraindicated. Data comparing the transcaval (TCv) to supra-aortic (SAo) approaches (transcarotid, transsubclavian, and transaxillary) for TAVR are lacking. We aimed to compare the outcomes and safety of TCv and SAo accesses for TAVR as alternatives to transfemoral TAVR. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all articles comparing TCv-TAVR against SAo-TAVR published until September 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM) and postoperative complications. A total of three studies with 318 TCv-TAVR and 179 SAo-TAVR patients were included. No statistically significant difference was found regarding in-hospital or 30-day ACM (relative risk [RR] 1.04, 95% confidence interval [CI] 0.47-2.34, p = 0.91), major bleeding, the need for blood transfusions, major vascular complications, and acute kidney injury. TCv-TAVR was associated with a non-statistically significant lower rate of neurovascular complications (RR 0.39, 95%CI 0.14-1.09, p = 0.07). These results suggest that both approaches may be considered as first-line alternatives to transfemoral TAVR, depending on local expertise and patients' anatomy. Additional data from long-term cohort studies are needed.
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Affiliation(s)
- Panagiotis Antiochos
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - Matthias Kirsch
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (M.K.); (A.N.)
| | - Pierre Monney
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - Georgios Tzimas
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - David Meier
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - Stephane Fournier
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - Clémence Ferlay
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (M.K.); (A.N.)
- Adult Intensive Care Unit, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Anna Nowacka
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (M.K.); (A.N.)
| | - Valentina Rancati
- Division of Anesthesiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland;
| | - Christophe Abellan
- Division of Internal Medicine, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland;
| | - Ioannis Skalidis
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - Olivier Muller
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
| | - Henri Lu
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (P.M.); (G.T.); (D.M.); (S.F.); (C.F.); (I.S.); (O.M.)
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6
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van Wely M, van Nieuwkerk AC, Rooijakkers M, van der Wulp K, Gehlmann H, Verkroost M, van Garsse L, Geuzebroek G, Baz JA, Tchétché D, De Brito FS, Barbanti M, Kornowski R, Latib A, D'Onofrio A, Ribichini F, Dangas G, Mehran R, Delewi R, van Royen N. Transaxillary versus transfemoral access as default access in TAVI: A propensity matched analysis. Int J Cardiol 2024; 394:131353. [PMID: 37696359 DOI: 10.1016/j.ijcard.2023.131353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/10/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Transfemoral (TF) access is default in transcatheter aortic valve implantation (TAVI). Transaxillary (TAx) access has been shown to be a safe alternative in case of prohibitive iliofemoral anatomy, but whether TAx as preferred access has similar safety and efficacy as TF access is unknown. The aim of this study was to compare outcomes between patients treated with self-expanding devices using TF or TAx route as preferred access in TAVI. METHODS A single center cohort of 354 patients treated using TAx as preferred access and a multi-center cohort of 5980 patients treated using TF access were compared. Propensity score matching was used to reduce selection bias and potential confounding. After propensity score matching, each group consisted of 322 patients. Clinical outcomes according to VARC-2 were compared using chi-square test. RESULTS In 6334 patients undergoing TAVI, mean age was 81.4 ± 7.0 years, 57% was female and median logistic EuroSCORE was 14.7% (IQR 9.5-22.6). In the matched population (age 79.3 ± 7.0, 50% female, logistic EuroSCORE 13.4%, IQR 9.0-21.5), primary outcomes 30-day and one-year all-cause mortality were similar between Tax and TF groups (30 days: 5% versus 6%, p = 0.90; 1 year: 20% versus 16%, p = 0.17). Myocardial infarction was more frequent in patients undergoing Tax TAVI compared with TF (4% versus 1%, p = 0.05), but new permanent pacemakers were less frequently implanted (12% versus 21%, p = 0.001). CONCLUSION TAx as preferred access is feasible and safe with outcomes that are comparable to TF access.
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Affiliation(s)
- Marleen van Wely
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Astrid C van Nieuwkerk
- Amsterdam UMC, University of Amsterdam, Heart Center; Department of Cardiology, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Maxim Rooijakkers
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Kees van der Wulp
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Helmut Gehlmann
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Michel Verkroost
- Department of Cardio-Thoracic surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Leen van Garsse
- Department of Cardio-Thoracic surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Guillaume Geuzebroek
- Department of Cardio-Thoracic surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - José Antonio Baz
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain.
| | | | - Fabio S De Brito
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil.
| | - Marco Barbanti
- Division of Cardiology, Policlinico-Vittorio Emanuele Hospital, University of Catania, Catania, Italy.
| | - Ran Kornowski
- Rabin Medical Center, Cardiology Department, Petach Tikva, Israel.
| | - Azeem Latib
- Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Montefiore Medical Center, Department of Interventional Cardiology, New York, USA.
| | | | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Ronak Delewi
- Amsterdam UMC, University of Amsterdam, Heart Center; Department of Cardiology, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
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7
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Srinivasan A, Wong F, Wang B. Transcatheter aortic valve replacement: Past, present, and future. Clin Cardiol 2024; 47:e24209. [PMID: 38269636 PMCID: PMC10788655 DOI: 10.1002/clc.24209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a ground-breaking, minimally invasive alternative to traditional open-heart surgery, primarily designed for elderly patients initially considered unsuitable for surgical intervention due to severe aortic stenosis. As a result of successful large-scale trials, TAVR is now being routinely applied to a broader spectrum of patients. In deciding between TAVR and surgical aortic valve replacement, clinicians evaluate various factors, including patient suitability and anatomy through preprocedural imaging, which guides prosthetic valve sizing and access site selection. Patient surgical risk is a pivotal consideration, with a multidisciplinary team making the ultimate decision in the patient's best interest. Periprocedural imaging aids real-time visualization but is influenced by anaesthesia choices. A comprehensive postprocedural assessment is critical due to potential TAVR-related complications. Numerous trials have demonstrated that TAVR matches or surpasses surgery for patients with diverse surgical risk profiles, ranging from extreme to low risk. However, long-term follow-up data, particularly in low-risk cases, remains limited, and the applicability of published results to younger patients is uncertain. This review delves into key TAVR studies, pinpointing areas for potential improvement while delving into the future of this innovative procedure. Furthermore, it explores the expanding role of TAVR technology in addressing other heart valve replacement procedures.
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Affiliation(s)
- Akash Srinivasan
- Division of Medical Sciences, Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Felyx Wong
- Guy's and St Thomas’ NHS Foundation TrustLondonUK
| | - Brian Wang
- Department of Metabolism, Digestion and Reproduction, Faculty of MedicineImperial College LondonLondonUK
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8
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Schaefer A, Bhadra OD, Conradi L, Westermann D, Kellner C, De Backer O, Bajoras V, Sondergaard L, Qureshi WT, Kakouros N, Aldrugh S, Amat-Santos I, Kaneko T, Harloff M, Teles R, Nolasco T, Neves JP, Abecasis M, Werner N, Lauterbach M, Sacha J, Krawczyk K, Trani C, Romagnoli E, Mangieri A, Condello F, Regueiro A, Brugaletta S, Biancari F, Niemelä M, Giannini F, Toselli M, Ruggiero R, Buono A, Maffeo D, Bruno F, Conrotto F, D'Ascenzo F, Savontaus M, Pykäri J, Ielasi A, Tespili M, Cimmino M, Albanese M, Biondi-Zoccai G, Corcione N, Morello A, Giordano A. Procedural success in transaxillary transcatheter aortic valve implantation according to type of transcatheter heart valve: results from the multicenter TAXI registry. Clin Res Cardiol 2024; 113:48-57. [PMID: 37138103 DOI: 10.1007/s00392-023-02216-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Transaxillary (TAx) transcatheter aortic valve implantation (TAVI) is a preferred alternative access in patients ineligible for transfemoral TAVI. AIMS This study used the Trans-AXillary Intervention (TAXI) registry to compare procedural success according to different types of transcatheter heart valves (THV). METHODS For the TAXI registry anonymized data of patients treated with TAx-TAVI were collected from 18 centers. Acute procedural, early and 1-month clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions. RESULTS From 432 patients, 368 patients (85.3%, SE group) received self-expanding (SE) THV and 64 patients (14.8%, BE group) received balloon-expandable (BE) THV. Imaging revealed lower axillary artery diameters in the SE group (max/min diameter in mm: 8.4/6.6 vs 9.4/6.8 mm; p < 0.001/p = 0.04) but a higher proportion of axillary tortuosity in BE group (62/368, 23.6% vs 26/64, 42.6%; p = 0.004) with steeper aorta-left ventricle (LV) inflow (55° vs 51°; p = 0.002) and left ventricular outflow tract (LVOT)-LV inflow angles (40.0° vs 24.5°; 0.002). TAx-TAVI was more often conducted by right sided axillary artery in the BE group (33/368, 9.0% vs 17/64, 26.6%; p < 0.001). Device success was higher in the SE group (317/368, 86.1% vs 44/64, 68.8%, p = 0.0015). In logistic regression analysis, BE THV were a risk factor for vascular complications and axillary stent implantation. CONCLUSIONS Both, SE and BE THV can be safely used in TAx-TAVI. However, SE THV were more often used and were associated with a higher rate of device success. While SE THV were associated with lower rates of vascular complications, BE THV were more often used in cases with challenging anatomical circumstances.
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Affiliation(s)
- Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.
| | - Oliver D Bhadra
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Ole De Backer
- The Heart Center-Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vilhelmas Bajoras
- The Heart Center-Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Department of Interventional Cardiology, Division of Cardiology and Vascular Diseases, Vilnius University, Hospital Santaros Clinics, Vilnius, Lithuania
| | - Lars Sondergaard
- The Heart Center-Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Waqas T Qureshi
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Nikolaos Kakouros
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Summer Aldrugh
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Ignacio Amat-Santos
- Cardiology Department, CIBERCV, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Morgan Harloff
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rui Teles
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Tiago Nolasco
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Jose Pedro Neves
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Miguel Abecasis
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Nikos Werner
- Department of Medicine 3, Barmherzige Brüder Hospital, Trier, Germany
| | | | - Jerzy Sacha
- Department of Cardiology, Institute of Medical Sciences, University Hospital, University of Opole, Opole, Poland
| | - Krzysztof Krawczyk
- Department of Cardiology, Institute of Medical Sciences, University Hospital, University of Opole, Opole, Poland
| | - Carlo Trani
- Institute of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Enrico Romagnoli
- Institute of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Francesco Condello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Ander Regueiro
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Salvatore Brugaletta
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Matti Niemelä
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Marco Toselli
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Rossella Ruggiero
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Andrea Buono
- Interventional Cardiology Unit, Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Diego Maffeo
- Interventional Cardiology Unit, Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Francesco Bruno
- Department of Medical Science, Division of Cardiology, Città Della Salute e della Scienza, Turin, Italy
| | - Federico Conrotto
- Department of Medical Science, Division of Cardiology, Città Della Salute e della Scienza, Turin, Italy
| | - Fabrizio D'Ascenzo
- Department of Medical Science, Division of Cardiology, Città Della Salute e della Scienza, Turin, Italy
| | - Mikko Savontaus
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Jouni Pykäri
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | | | - Maurizio Tespili
- Clinical and Interventional Cardiology Unit, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
| | - Michele Cimmino
- Interventional Cardiology Unit, Santa Lucia Clinic, S. Giuseppe Vesuviano, Naples, Italy
| | - Michele Albanese
- Interventional Cardiology Unit, Santa Lucia Clinic, S. Giuseppe Vesuviano, Naples, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Nicola Corcione
- Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy
| | - Alberto Morello
- Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy
| | - Arturo Giordano
- Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy
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Patail H, Kompella R, Hoover NE, Reis W, Masih R, Mather JF, Sutton TS, McKay RG. In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use. Cardiol Res 2023; 14:228-236. [PMID: 37304920 PMCID: PMC10257506 DOI: 10.14740/cr1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR). Methods We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O2 cohort) with 2,313 non-home O2 patients. Results Home O2 patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV1) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O2 cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O2 patients, home O2 patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O2 cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O2 cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001). Conclusion Home O2 patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.
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Affiliation(s)
- Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ritika Kompella
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Wyona Reis
- Department of Cardiology, Hartford Hospital, Hartford, CT, USA
| | - Rohit Masih
- Department of Internal Medicine, Hartford Hospital, Hartford, CT, USA
| | - Jeff F. Mather
- Department of Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Trevor S. Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
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10
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Singh I, Swisher J, Schreiber T. Percutaneous Transaxillary Impella Device Placement Resulting in Iatrogenic Subclavian Artery Pseudoaneurysm. Cureus 2023; 15:e40082. [PMID: 37425600 PMCID: PMC10327530 DOI: 10.7759/cureus.40082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023] Open
Abstract
Subclavian artery pseudoaneurysm (PSA) is a rare complication arising from transaxillary Impella device placement during high-risk percutaneous coronary intervention (PCI). Despite the increasing prevalence of Impella use, literature addressing this complication is scarce. This case emphasizes the limited existing evidence on subclavian artery PSA and highlights the importance of recognizing it as a potential risk. With high-risk PCI and Impella use gaining popularity, understanding this complication is crucial for early detection and appropriate management. A 62-year-old male with a past medical history of type II diabetes mellitus, peripheral artery disease, hypertension, and chronic tobacco use presents with recurrent episodes of exertional chest pain and dyspnea. Initial workup with an electrocardiogram showed ST-segment elevations in the anteroseptal leads. The patient underwent right- and left-sided cardiac catheterization, which revealed severe stenosis of the left anterior descending artery and findings of cardiogenic shock. The patient required mechanical circulatory support with a percutaneous left ventricular assist device during the procedure; this was placed via transaxillary approach due to the patient having peripheral artery disease in bilateral femoral arteries. The patient had a complicated clinical course, but the patient's clinical picture slowly improved, and the percutaneous left ventricular assist device was removed. Roughly six weeks after the removal of the device, the patient developed a large fluid collection in the chest wall anterior to the left shoulder. Imaging revealed a ruptured left distal subclavian artery PSA. The patient was promptly taken to the catheterization laboratory and a covered stent was deployed over the site of the PSA. Repeat angiography revealed brisk flow through the left subclavian artery into the axillary artery with no extravasation into the chest wall.
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Affiliation(s)
- Inderpal Singh
- Internal Medicine, Ascension St. John Hospital, Detroit, USA
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11
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Bertoglio L, Oderich G, Melloni A, Gargiulo M, Kölbel T, Adam DJ, Di Marzo L, Piffaretti G, Agrusa CJ, Van den Eynde W. Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures. Eur J Vasc Endovasc Surg 2023; 65:729-737. [PMID: 36740094 DOI: 10.1016/j.ejvs.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/08/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. METHODS A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. RESULTS Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 - 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 - 12.1; p = .026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 - 9.6; p = .019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 - 20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 - 9.0; p = .013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 - 13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 - 31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p < .001). CONCLUSION AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gustavo Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Luca Di Marzo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University, Rome, Italy
| | - Gabriele Piffaretti
- Vascular Surgery and Interventional Radiology, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Centre, New York, NY, USA
| | - Wouter Van den Eynde
- Department of Vascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
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12
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Wittig T, Sabanov A, Schmidt A, Scheinert D, Steiner S, Branzan D. Feasibility and Safety of Percutaneous Axillary Artery Access in a Prospective Series of 100 Complex Aortic and Aortoiliac Interventions. J Clin Med 2023; 12:jcm12051959. [PMID: 36902745 PMCID: PMC10003984 DOI: 10.3390/jcm12051959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
We aimed to review the feasibility and safe use of the percutaneous axillary artery (AxA, 100 patients) approach for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA, 90 patients) using fenestrated, branched, and chimney stent grafts and other complex endovascular procedures (10 patients) necessitating AxA access. Percutaneous puncture of the AxA in its third segment was performed using sheaths sized between 6 to 14F. For closing puncture sites greater than 8F, two Perclose ProGlide percutaneous vascular closure devices (PVCDs) (Abbott Vascular, Santa Clara, CA, USA) were deployed in the pre-close technique. The median maximum diameter of the AxA in the third segment was 7.27 mm (range 4.50-10.80). Device success, defined as successful hemostasis by PVCD, was reported in 92 patients (92.0%). As recently reported results in the first 40 patients suggested that adverse events, including vessel stenosis or occlusion, occurred only in cases with a diameter of the AxA < 5 mm, in all subsequent 60 cases AxA access was restricted to a vessel diameter ≥ 5 mm. In this late group, no hemodynamic impairment of the AxA occurred except in six early cases below this diameter threshold, all of which could be repaired by endovascular measures. Overall mortality at 30 days was 8%. In conclusion, percutaneous approach of the AxA in its third segment is feasible and represents a safe alternative access to open access for complex endovascular aorto-iliac procedures. Complications are rare, especially if the maximum diameter of the access vessel (AxA) is ≥5 mm.
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Affiliation(s)
- Tim Wittig
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
| | - Arsen Sabanov
- Department of Vascular Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Dierk Scheinert
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Sabine Steiner
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-9718770; Fax: +49-341-9718779
| | - Daniela Branzan
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
- Department of Vascular Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
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13
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Tresson P, Faveur A, Mennecart T, André R, Bordet M, Millon A. Percutaneous Axillary Artery Puncture: An Efficient Approach for Upper Extremity Access. Ann Vasc Surg 2023:S0890-5096(23)00052-3. [PMID: 36739081 DOI: 10.1016/j.avsg.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/14/2023] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim was to analyze the anatomic feasibility of the percutaneous axillary access (PAXA) using cadaverous models and then to analyze the complications associated with PAXA during Fenestrated or Branched Endovascular Aneurysm Repair (F/BEVAR) procedures. METHODS Cadaverous models were used to analyze axillary pedicle after a PAXA on an initial anatomical investigation. A subclavian approach was performed after puncture to assess the injuries caused by the needle. Then, in an observational study, patients who underwent F/BEVAR using a PAXA between July 2019 and July 2021 were included. PAXA-related events and complications were monitored. RESULTS Eleven dissections were performed on cadavers. The axillary vein was injured twice (18.2%); the puncture site on the axillary artery was found on the arterial proximal part, behind the clavicle. Fifty-three patients underwent a F/BEVAR using a PAXA. The mean (SD) age of patients was 74.5 (9.7) years. Most indications for endovascular repair were para-renal aneurysms (66%). Two Proglide® closure devices served to close arterial access in all procedures. Adjunct balloon inflation was used in 19 (35.8%) patients. There were 5 (9.4%) PAXA-related events included preoperative blush in 2 (3.8%) patients, axillary artery dissection in 2 (3.8%), and 1 (1.9%) axillary artery stenosis. Five patients (9.4%) had a postoperative axillary hematoma without need for additional surgical procedure. No PAXA-related complication was found after discharge (mean [SD] 11.7 [7.4] months following surgery). CONCLUSIONS Percutaneous axillary artery access was an efficient upper extremity access and associated with a low rate of PAXA-related events.
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Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de chirurgie vasculaire et endovasculaire, Bron, France; Intestinal Stroke Center, Centre rHodANien d'isChemie intEStinale (CHANCES Network, Lyon), Lyon, France.
| | - Adama Faveur
- Officer cadet at the French Military Medical School. École de Santé des Armées, Bron, France; Université Claude Bernard Lyon 1 (Univ Lyon), Villeurbanne, France
| | - Thibaut Mennecart
- Officer cadet at the French Military Medical School. École de Santé des Armées, Bron, France; Université Claude Bernard Lyon 1 (Univ Lyon), Villeurbanne, France
| | - Rémi André
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de chirurgie vasculaire et endovasculaire, Bron, France; Université Claude Bernard Lyon 1 (Univ Lyon), Villeurbanne, France
| | - Marine Bordet
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de chirurgie vasculaire et endovasculaire, Bron, France; Université Claude Bernard Lyon 1 (Univ Lyon), Villeurbanne, France
| | - Antoine Millon
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de chirurgie vasculaire et endovasculaire, Bron, France; Université Claude Bernard Lyon 1 (Univ Lyon), Villeurbanne, France
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14
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Domoto S, Nakazawa K, Yamaguchi J, Hayakawa M, Otsuki H, Inagaki Y, Saito C, Arashi H, Kogure T, Niinami H. Minimum-incision trans-subclavian transcatheter aortic valve replacement with regional anesthesia. J Cardiol 2023; 81:131-137. [PMID: 35882612 DOI: 10.1016/j.jjcc.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Minimum-incision trans-subclavian transcatheter aortic valve replacement (MITS-TAVR) is usually performed in patients who are contraindicated for transfemoral TAVR, under regional anesthesia (RA). This study aimed to evaluate the safety and efficacy of MITS-TAVR under RA compared to MITS-TAVR under general anesthesia (GA). METHODS This single-center observational study included 44 consecutive patients who underwent MITS-TAVR under RA (RA group, n = 19) and GA (GA group, n = 25). RA was achieved using an ultrasound-guided nerve block. RESULTS The rates of respiratory disease (RA vs. GA, 36.8 % vs. 4.0 %; p < 0.01) and dialysis (79.0 % vs. 0 %; p < 0.01) were significantly higher in the RA group. STS score was significantly higher in the RA group (RA vs. GA, 10.8 ± 1.06 % vs. 7.87 ± 0.93 %; p < 0.01). Both groups had a 100 % procedural success rate. The two groups showed comparable operation room stay times (RA vs. GA, 160 ± 6.96 min vs. 148 ± 5.90 min; p = 0.058). The mean rate of change in blood pressure, used as an index of hemodynamic stability, was significantly lower in the RA group (RA vs. GA, 19.0 ± 3.4 % vs. 35.5 ± 3.0 %; p < 0.01). No in-hospital deaths occurred in either group. One case of minor dissection occurred in the GA group (RA vs.GA, 0 % vs. 4.0 %, p = 0.378). The intensive care unit stay (RA vs. GA, 0.21 ± 0.11 days vs. 1.24 ± 0.10 days; p < 0.01) and hospital stay (RA vs. GA, 7.00 ± 1.73 days vs. 12.2 ± 1.44 days; p < 0.01) were significantly shorter in the RA group. CONCLUSIONS MITS-TAVR under RA is safe and effective and might be a promising alternative approach. It could ensure intraoperative hemodynamic stability and shorten intensive care unit and hospital stays.
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Affiliation(s)
- Satoru Domoto
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Keisuke Nakazawa
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Minako Hayakawa
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisao Otsuki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yusuke Inagaki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Chihiro Saito
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroyuki Arashi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomohito Kogure
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
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15
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Koziarz A, Kennedy SA, Awad El-Karim G, Tan KT, Oreopoulos GD, Kalra S, Etz CD, Rajan DK, Mafeld S. Vascular Closure Devices For Axillary Artery Access: A Systematic Review and Meta-Analysis. J Endovasc Ther 2023:15266028221147451. [PMID: 36625294 DOI: 10.1177/15266028221147451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery. MATERIALS AND METHODS MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient-level data. RESULTS Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%-89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%-10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%-7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%-5.7%, I2=0%), infection <1% (95% CI: 0%-5.7%, I2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%-4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80-0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04-1.40, p=0.013). CONCLUSIONS Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications. CLINICAL IMPACT Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.
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Affiliation(s)
- Alex Koziarz
- Department of Radiology, McMaster University, Hamilton, ON, Canada
| | - Sean A Kennedy
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ghassan Awad El-Karim
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Kong T Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - George D Oreopoulos
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Vascular Surgery, University Health Network, Toronto, ON, Canada
| | - Sanjog Kalra
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christian D Etz
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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16
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Tokuda T, Yamamoto M. Vascular management during transcatheter aortic valve replacement. Cardiovasc Interv Ther 2023; 38:18-27. [PMID: 36447120 DOI: 10.1007/s12928-022-00900-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/18/2022] [Indexed: 12/02/2022]
Abstract
Transcatheter aortic valve replacement (TAVR), as an alternative to open heart surgery, has been established as the standard therapy for patients with severe aortic valve stenosis. Vascular access management, the first step in a TAVR procedure, should be managed properly. Moreover, the transfemoral and alternatives such as the transaxillary/subclavian, transcarotid, transapical, and transcaval approaches are considered access routes during TAVR. More than 90% of cases can be treated via the transfemoral approach in the current TAVR era, whereas other approaches should be considered in patients in whom the transfemoral approach is not suitable. Vascular complications regardless of access route differences are a specific issue of TAVR caused by the use of large sheaths. With the increased number of TAVR cases, we must manage vascular complications and decrease the morbidity and mortality rates associated with TAVR procedures. Thus, this study aimed to review the vascular complications during TAVR and summarize their prognosis, prevention, and adequate management.
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Affiliation(s)
- Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Aichi, Japan.
| | - Masanori Yamamoto
- Department of Cardiology, Nagoya Heart Center, Nagoya, Aichi, Japan. .,Department of Cardiology, Toyohashi Heart Center, Toyohashi, Aichi, Japan. .,Department of Cardiology, Gifu Heart Center, Gifu, Japan.
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17
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Lauten P, El-Garhy M, Al-Jassem M, Lapp H. Successful management of a bleeding complication during transaxillary transcatheter aortic-valve implantation: a case report. Eur Heart J Case Rep 2022; 6:ytac280. [PMID: 35865224 PMCID: PMC9297097 DOI: 10.1093/ehjcr/ytac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/01/2022] [Accepted: 06/29/2022] [Indexed: 11/14/2022]
Abstract
Background The axillary artery is an alternative access route for transcatheter aortic-valve implantation (TAVI) in patients who have unfavourable femoral arteries as well as comorbidities which preclude surgery. Transaxillary TAVI (TAx-TAVI), with a complete non-transfemoral approach, is a feasible and safe alternative even if complications like vascular closure device failure with bleeding occurs. Case summary We describe here a simplified non-transfemoral TAx-TAVI approach in a 71-year-old patient with pulmonary oedema due to severe symptomatic aortic stenosis with a prohibitively high surgical risk (Society of Thoracic Surgeons Mortality 11.9%) and extensive peripheral artery disease that rendered the femoral arteries unsuitable for access. Importantly, this strategy also allows for successful management of bleeding events, particularly those associated with vascular closure device failure, by the use of a new covered stent device. The patient was discharged on Day 6 after admission in stable conditions. In short-term follow-up (30 days), he is asymptomatic with normal left-ventricular function. Discussion The TAx-TAVI is a promising alternative to transfemoral TAVI approach. Patient safety, even during bleeding complications, can be guaranteed with appropriate preparation.
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Affiliation(s)
- Philipp Lauten
- Department of Cardiology, Heart Center, Zentralklinik Bad Berka , Robert-Koch-Allee 9 , 99437 Bad Berka, Germany
| | - Mohamed El-Garhy
- Department of Cardiology, Heart Center, Zentralklinik Bad Berka , Robert-Koch-Allee 9 , 99437 Bad Berka, Germany
| | - Mahmoud Al-Jassem
- Department of Heart Surgery, Heart Center, Zentralklinik Bad Berka , 99437 Bad Berka , Germany
| | - Harald Lapp
- Department of Cardiology, Heart Center, Zentralklinik Bad Berka , Robert-Koch-Allee 9 , 99437 Bad Berka, Germany
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18
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Aimanan K, Pian PM, Pillay KVK, Hayati F, Hussein H. Open axillary approach alternative access for stenting of external iliac total occlusion. Radiol Case Rep 2022; 17:1959-1962. [PMID: 35432678 PMCID: PMC9010893 DOI: 10.1016/j.radcr.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
A primary endovascular approach is the mainstay of intervention for type C aortoiliac disease. When the femoral artery is unsuitable, upper extremity access can be critical in the setting of severe tortuosity or occlusive disease. The axillary artery represents alternative upper extremity access that may accommodate larger sheath sizes for therapeutic interventions. A 44-year-old gentleman with a history of right below-knee amputation was referred to the vascular unit with a left foot non-healing wound post wound debridement for diabetic foot ulcer. On examination, the left foot was non-salvageable with pitting oedema extended until knee level. Left lower limb pulses were non-palpable from femoral downwards. A biphasic signal was audible at the left femoral and monophasic at the popliteal. Photoplethysmography showed poor flow distally. Computed tomography angiogram revealed a 12 cm long segment total occlusion of the left external iliac artery just below the bifurcation of iliac vessel. On the right side, there was a long segment occlusion of the superficial femoral artery and calcified common femoral artery. The left axillary artery was used as an access and angioplasty was performed successfully. The advantages of upper extremity access in the axillary artery include the relatively large size and lower atherosclerotic burden. Larger profile stents for aortoiliac occlusion can easily be handled with a good strength through an axillary approach which is antegrade compared to a retrograde femoral approach. With the advancement of safety features of endovascular devices complications with an axillary approach have become less in the recent era.
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19
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Lederman RJ, Babaliaros VC, Lisko JC, Rogers T, Mahoney P, Foerst JR, Depta JP, Muhammad KI, McCabe JM, Pop A, Khan JM, Bruce CG, Medranda GA, Wei JW, Binongo JN, Greenbaum AB. Transcaval Versus Transaxillary TAVR in Contemporary Practice: A Propensity-Weighted Analysis. JACC Cardiovasc Interv 2022; 15:965-975. [PMID: 35512920 PMCID: PMC9138050 DOI: 10.1016/j.jcin.2022.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
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.
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Affiliation(s)
- Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - Vasilis C Babaliaros
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - John C Lisko
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA; Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Paul Mahoney
- Division of Cardiology, The Sentara Heart Center, Norfolk, Virginia, USA
| | - Jason R Foerst
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Jeremiah P Depta
- Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, New York, USA
| | | | - James M McCabe
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Andrei Pop
- AMITA Health Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Jaffar M Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Giorgio A Medranda
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jane W Wei
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jose N Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Adam B Greenbaum
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA. https://twitter.com/AdamGreenbaumMD
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20
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Sugiura A, Sudo M, Al-Kassou B, Shamekhi J, Silaschi M, Wilde N, Sedaghat A, Becher UM, Weber M, Sinning JM, Grube E, Nickenig G, Charitos EI, Zimmer S. Percutaneous trans-axilla transcatheter aortic valve replacement. Heart Vessels 2022; 37:1801-1807. [PMID: 35505257 PMCID: PMC9399016 DOI: 10.1007/s00380-022-02082-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/15/2022] [Indexed: 11/26/2022]
Abstract
The left axillary artery is an attractive alternative access route for transcatheter aortic valve replacement (TAVR) and may provide better outcomes compared to other alternatives. Nevertheless, there remain concerns about vascular complications, lack of compressibility, and thorax-related complications. Between March 2019 and March 2021, 13 patients underwent transaxillary TAVR for severe aortic stenosis at the University Hospital Bonn. The puncture was performed with a puncture at the distal segment of the axillary artery through the axilla, with additional femoral access for applying a safety wire inside the axillary artery. Device success was defined according to the VARC 2 criteria. The study participants were advanced in age (77 ± 9 years old), and 54% were female, with an intermediate risk for surgery (STS risk score 4.7 ± 2.0%). The average diameter of the distal segment of the axillary artery was 5.8 ± 1.0 mm (i.e., the puncture site) and 7.6 ± 0.9 mm for the proximal axillary artery. Device success was achieved in all patients. 30-day major adverse cardiac and cerebrovascular events were 0%. With complete percutaneous management, stent-graft implantation was performed at the puncture site in 38.5% of patients. Minor bleeding was successfully managed with manual compression. Moreover, no thorax-related complications, hematomas, or nerve injuries were observed. Percutaneous trans-axilla TAVR was found to be feasible and safe. This modified approach may mitigate the risk of bleeding and serious complications in the thorax and be less invasive than surgical alternatives.
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Affiliation(s)
- Atsushi Sugiura
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Mitsumasa Sudo
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Baravan Al-Kassou
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Jasmin Shamekhi
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Alexander Sedaghat
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Ulrich Marc Becher
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Jan-Malte Sinning
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Eberhard Grube
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Efstratios I Charitos
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany.
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21
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Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EUROINTERVENTION 2022; 17:1514-1522. [PMID: 34794935 PMCID: PMC9896400 DOI: 10.4244/eij-d-21-00549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND As transaxillary (TAx) access has become the most common alternative to transfemoral (TF) transcatheter aortic valve replacement (TAVR), there is increasing use of a percutaneous approach. AIMS This study sought to determine whether there are differences in outcomes using a percutaneous access versus cutdown for TAx TAVR. METHODS Using data from the STS/ACC TVT Registry, consecutive patients undergoing TAx TAVR with balloon-expandable valves between July 2015 and December 2020 were included. Propensity score-based matching was performed to evaluate the association between method of TAx access and outcomes. RESULTS Of 4,219 patients, 1,140 (27.0%) underwent percutaneous access and 3,079 (73.0%) had surgical cutdown for TAx TAVR, with the proportion of percutaneous cases increasing over time. After propensity matching, there were no significant baseline differences between patients undergoing TAx access by either approach. At 30 days, there were similar rates of all-cause mortality (4.8% in percutaneous patients vs 4.1% in surgical patients; p=0.40) and stroke (7.7% vs 6.5%; p=0.25). Those undergoing percutaneous TAx access were more likely to receive conscious sedation and have less need for the intensive care unit (ICU). Percutaneous access was associated with a higher rate of major vascular complication (3.0% vs 1.5% in surgical patients; p=0.02) but not life-threatening bleeding (0.3% vs 0.1%; p=0.31). CONCLUSIONS This study supports the safety and efficacy of percutaneous TAx TAVR compared to traditional surgical cutdown. Percutaneous access was associated with a shorter ICU stay and a higher rate of major vascular complication without an increase in life-threatening bleeding.
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Affiliation(s)
- Christine J. Chung
- UW Medicine Heart Institute, 1959 NE Pacific Street, Box 356171, Seattle, WA 98195-6171, USA
| | | | | | - Thom G. Dahle
- CentraCare Heart & Vascular Center, St. Cloud, MN, USA
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22
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Percutaneous proximal axillary artery versus femoral artery access for endovascular interventions. J Vasc Surg 2022; 76:165-173. [PMID: 35351603 DOI: 10.1016/j.jvs.2022.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/11/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The primary objective of this study is to describe and illustrate the technique of ultrasound-guided percutaneous proximal axillary artery (PAA) access, and secondarily to evaluate the versatility and safety of this approach in peripheral, visceral, and aortic endovascular interventions. METHODS This is a single-center retrospective review of all peripheral, visceral, and aortic endovascular cases using percutaneous PAA access from February 2019 to March 2021 compared with a sample of an equivalent number of consecutive cases completed via percutaneous common femoral artery (CFA) access during the same time period. Access entry success, minor and major access site complications within 30 days, major adverse events within 30 days, demographics, and procedural details were analyzed using standard statistical analyses. RESULTS A total of 115 accesses-59 PAA and 56 CFA-were reviewed during the study period. Group demographics were not significantly different. Access entry success was achieved in 58 (98.3%) and 56 (100%) of PAA and CFA accesses, respectively, with no statistically significant difference. There were no significant differences in minor access-site complications (13.6% vs 5.4%; P = .21) major access site complications (3.4% vs 7.1%; P = .43), or major adverse events (6.8% vs 5.4%). between the PAA and CFA groups. With respect to versatility, PAA cases had a significantly greater mean number of vessels intervened on per procedure compared with CFA access (2.59 ± 1.31 vs 1.95 ± 0.98; P < .01). A wide range of target vessels were intervened on in both groups. PAA cases had significantly more bilateral lower leg interventions (28.8% vs 12.5%; P = .04). PAA access had a significantly longer mean procedure time (103.2 minutes vs 58.63 minutes; P < .001) and fluoroscopy time (18.21 minutes vs 12.87 minutes; P = .02). CONCLUSIONS The PAA is a feasible, versatile, and safe percutaneous access option for endovascular intervention. The in-line trajectory from this site facilitates visceral, renal, aortic, and bilateral lower extremity interventions with ease. Outcomes, complications, and major adverse events are similar to those of conventional CFA access in the short term.
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23
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Lind A, Zubarevich A, Ruhparwar A, Totzeck M, Jánosi RA, Rassaf T, Al-Rashid F. The Transaxillary Approach via Prosthetic Conduit for Transcatheter Aortic Valve Replacement With the New-Generation Balloon-Expandable Valves in Patients With Severe Peripheral Artery Disease. Front Cardiovasc Med 2022; 8:795263. [PMID: 35097012 PMCID: PMC8793794 DOI: 10.3389/fcvm.2021.795263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The left subclavian artery (LSA) is an infrequently used alternative access route for patients with severe peripheral artery disease (PAD) in patients who underwent transcatheter aortic valve replacement (TAVR). We report a new endovascular approach for TAVR combining an axillary prosthetic conduit-based access technique with new-generation balloon-expandable TAVR prostheses. Methods and Results: Between January 2020 and December 2020, 251 patients underwent TAVR at the West German Heart and Vascular Center. Of these, 10 patients (3.9%) were deemed to be treated optimally by direct surgical exposure of the left or right axillary artery via a surgically adapted prosthetic conduit. All procedures were performed under general anesthesia. One procedural stroke occurred due to severe calcification of the aortic arch. No specific complications of the subclavian access site (vessel rupture, vertebral, or internal mammary ischemia) were reported. Two minor bleedings from the access site could be treated conservatively. No surgical revision was necessary. Conclusion: The axillary prosthetic conduit-based access technique using new-generation balloon-expandable valves allows safe and successful TAVR in a subgroup of patients with a high risk of procedural complications due to severe peripheral vascular disease. Considering the increasing number of patients referred for TAVR, this approach could represent an alternative for patients with limited access sites.
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Affiliation(s)
- Alexander Lind
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
- *Correspondence: Alexander Lind
| | - Alina Zubarevich
- Department of Heart Surgery, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Heart Surgery, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
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24
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Yufa A, Mikael A, Gautier G, Yoo J, Vo TD, Tayyarah M, Behseresht D, Hsu J, Andacheh I. Percutaneous Axillary Artery Access for Peripheral and Complex Endovascular Interventions: Clinical Outcomes and Cost Benefits. Ann Vasc Surg 2021; 83:176-183. [PMID: 34954376 DOI: 10.1016/j.avsg.2021.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 11/13/2021] [Accepted: 11/22/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to determine the safety, efficacy, and applicability of percutaneous axillary artery (pAxA) access in patients requiring upper extremity large sheath access during complex aortic, cardiac, and peripheral endovascular procedures. We also take this opportunity to address the potential cost-benefits offered by pAxA access compared to open upper extremity access. METHODS A total of 26 consecutive patients, between June 2018 and October 2020, underwent endovascular intervention, requiring upper extremity access (UEA). Ultrasound-guided, percutaneous access of the axillary artery was used in all 26 patients with off-label use of pre-close technique with Perclose ProGlide closure devices. Access sites accommodated sheath sizes that ranged from 6 to 14 French (F). End points were technical success and access site-related complications including isolated neuropathies, hematoma, distal embolization, access-site thrombosis, and post-operative bleeding requiring secondary interventions. Technical success was defined as successful arterial closure intraoperatively with no evidence of stenosis, occlusion, or persistent bleeding, requiring additional intervention. RESULTS Of the 26 patients requiring pAxA access, 15 underwent complex endovascular aortic aneurysm repairs (EVAR) with branched, fenestrated, snorkel, or parallel endografts, 6 underwent peripheral vascular interventions, and 5 underwent cardiac interventions. Fifty-three percent accommodated sheath sizes of 12F or higher. Technical success was achieved in 100% of cases with no major perioperative access complications requiring additional open or endovascular procedures. In our series, we had one post-operative mortality secondary to myocardial infarction in a patient with significant coronary artery disease. CONCLUSIONS Our data again demonstrated the proposed safety and efficacy attributable to pAxA access, while extending its application to wide spectrum of endovascular interventions which included peripheral or coronary vascular in addition to complex EVAR.
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Affiliation(s)
- Ann Yufa
- Albert Einstein Medical Center, 5501 Old York Road, Klein 510, PHILADELPHIA, PENNSYLVANIA 19141; University of California, Riverside School of Medicine, 900 University Ave., RIVERSIDE, CALIFORNIA 92521.
| | - Amarseen Mikael
- University of California, Riverside School of Medicine, 900 University Ave., RIVERSIDE, CALIFORNIA 92521; Riverside Community Hospital, 4445 Magnolia Ave., RIVERSIDE, CALIFORNIA 92501
| | - Gloryanne Gautier
- Albert Einstein Medical Center, 5501 Old York Road, Klein 510, PHILADELPHIA, PENNSYLVANIA 19141
| | - Joseph Yoo
- Albert Einstein Medical Center, 5501 Old York Road, Klein 510, PHILADELPHIA, PENNSYLVANIA 19141
| | - Trung Duong Vo
- Kaiser Permanente, Southern California Medical Group, 9961 Sierra Ave., Department of Surgery, FONTANA, CALIFORNIA 92335
| | - Majid Tayyarah
- Kaiser Permanente, Southern California Medical Group, 9961 Sierra Ave., Department of Surgery, FONTANA, CALIFORNIA 92335
| | - Darian Behseresht
- Kaiser Permanente, Southern California Medical Group, 9961 Sierra Ave., Department of Surgery, FONTANA, CALIFORNIA 92335
| | - Jeffrey Hsu
- Kaiser Permanente, Southern California Medical Group, 9961 Sierra Ave., Department of Surgery, FONTANA, CALIFORNIA 92335
| | - Iden Andacheh
- University of California, Riverside School of Medicine, 900 University Ave., RIVERSIDE, CALIFORNIA 92521; Kaiser Permanente, Southern California Medical Group, 9961 Sierra Ave., Department of Surgery, FONTANA, CALIFORNIA 92335
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25
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Brachial and axillary artery vascular access for endovascular interventions. Ann Vasc Surg 2021; 81:292-299. [PMID: 34775017 DOI: 10.1016/j.avsg.2021.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/28/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Endovascular access is usually achieved through the common femoral artery due to its large size and accessibility. Access through the upper extremity can however be necessary due to anatomic reasons, obesity, or peripheral arterial disease. The two main methods of access are surgical cutdown and percutaneous puncture. In this single-centre retrospective cohort study we compared complication risks for both surgical cutdown and percutaneous puncture of an upper arm approach. MATERIALS AND METHODS Data was obtained from patients receiving endovascular access through the brachial or axillary artery between 2005 and 2018. A total of 109 patients were included. Patient demographics including age, sex, medical history, smoking status, and actual medication were registered, as well as postoperative complications including hematoma, thrombosis, dissection, infection, pseudoaneurysm, nerve injury, reoperation, and readmission. RESULTS Access was achieved through surgical cutdown in 53% (n=58) and through percutaneous puncture in 47% (n=51) of patients. Fifty-eight percent (n=63) received access via the brachial artery and 42% (n=46) via the axillary artery. Complication rate was 25.0% (3 of 12) for surgical cutdown via the brachial artery, 29.4% (15 of 51) for percutaneous puncture via the brachial artery, and 10.9% (5 of 46) for surgical cutdown via the axillary artery. Major complication rate was 8.3% (1 of 12) for surgical cutdown via the brachial artery, 13.7% (7 of 51) for percutaneous puncture via the brachial artery, and 4.3% (2 of 46) for surgical cutdown via the axillary artery. There was no association between baseline patient characteristics and complication rate. CONCLUSIONS In this non-randomized retrospective study, surgical cutdown via the axillary artery was the safest option with fewest complications, but selection of patients may have blurred the results. Surgical cutdown and percutaneous puncture seem equally safe in terms of complication rate in the brachial artery.
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26
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Mach M, Okutucu S, Kerbel T, Arjomand A, Fatihoglu SG, Werner P, Simon P, Andreas M. Vascular Complications in TAVR: Incidence, Clinical Impact, and Management. J Clin Med 2021; 10:jcm10215046. [PMID: 34768565 PMCID: PMC8584339 DOI: 10.3390/jcm10215046] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/23/2021] [Accepted: 10/24/2021] [Indexed: 12/12/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.
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Affiliation(s)
- Markus Mach
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (T.K.); (P.W.); (P.S.); (M.A.)
- Correspondence: ; Tel.: +43-1-40400-52620
| | - Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, 06520 Ankara, Turkey;
| | - Tillmann Kerbel
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (T.K.); (P.W.); (P.S.); (M.A.)
| | - Aref Arjomand
- Department of Cardiology, St. John of God Hospital, Geelong, VIC 3220, Australia;
| | | | - Paul Werner
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (T.K.); (P.W.); (P.S.); (M.A.)
| | - Paul Simon
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (T.K.); (P.W.); (P.S.); (M.A.)
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (T.K.); (P.W.); (P.S.); (M.A.)
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Jiménez-Quevedo P, Nombela-Franco L, Muñoz-García E, Del Valle-Fernández R, Trillo R, de la Torre Hernández JM, Salido L, Elizaga J, Ojeda S, Sánchez Gila J, García Del Blanco B, Berenguer A, Lasa-Larraya G, Urbano Carrillo C, Albarrán A, Ruiz-Salmerón R, Moreu J, Gheorghe L, Arzamendi D, Yanes-Bowden G, Díaz J, Pérez-Moreiras I, Artaiz M, Vaquerizo B, Cruz-González I, Ruiz-Quevedo V, Blanco-Mata R, Baz JA, Villa M, Ortiz de Salazar Á, Tascón-Quevedo V, Casellas S, Moreno R. Early clinical outcomes after transaxillary versus transfemoral TAVI. Data from the Spanish TAVI registry. ACTA ACUST UNITED AC 2021; 75:479-487. [PMID: 34711513 DOI: 10.1016/j.rec.2021.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access. METHODS We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics. RESULTS A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively). CONCLUSIONS Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.
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Affiliation(s)
- Pilar Jiménez-Quevedo
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain.
| | - Luis Nombela-Franco
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Erika Muñoz-García
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | - Ramiro Trillo
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - José M de la Torre Hernández
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - Luisa Salido
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jaime Elizaga
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Soledad Ojeda
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Joaquín Sánchez Gila
- Servicio de Cardiología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Alberto Berenguer
- Servicio de Cardiología, Hospital General Universitario de Valencia, Valencia, Spain
| | | | | | - Agustín Albarrán
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - José Moreu
- Servicio de Cardiología, Hospital Virgen de la Salud, Toledo, Spain
| | - Livia Gheorghe
- Servicio de Cardiología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Dabit Arzamendi
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Geoffrey Yanes-Bowden
- Servicio de Cardiología, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - José Díaz
- Servicio de Cardiología, Hospital Universitario Juan Ramón Jimenez, Huelva, Spain
| | | | - Miguel Artaiz
- Servicio de Cardiología, Clínica Universitaria de Navarra, Pamplona, Navarra, Spain
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Instituto de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Ignacio Cruz-González
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | | | | | - José Antonio Baz
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Manuel Villa
- Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Valentín Tascón-Quevedo
- Servicio de Cirugía Cardiaca, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Sandra Casellas
- Servicio de Cirugía Cardiaca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Raúl Moreno
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IDIPAZ), Madrid, Spain
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28
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Perrin N, Bonnet G, Leroux L, Ibrahim R, Modine T, Ben Ali W. Transcatheter Aortic Valve Implantation: All Transfemoral? Update on Peripheral Vascular Access and Closure. Front Cardiovasc Med 2021; 8:747583. [PMID: 34660747 PMCID: PMC8511676 DOI: 10.3389/fcvm.2021.747583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 12/19/2022] Open
Abstract
Transfemoral access remains the most widely used peripheral vascular approach for transcatheter aortic valve implantation (TAVI). Despite technical improvement and reduction in delivery sheath diameters of all TAVI platforms, 10-20% of patients remain not eligible to transfemoral TAVI due to peripheral artery disease. In this review, we aim at presenting an update of recent data concerning transfemoral access and percutaneous closure devices. Moreover, we will review peripheral non-transfemoral alternative as well as caval-aortic accesses and discuss the important features to assess with pre-procedural imaging modalities before TAVI.
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Affiliation(s)
- Nils Perrin
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada.,Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Guillaume Bonnet
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
| | - Lionel Leroux
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
| | - Réda Ibrahim
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
| | - Thomas Modine
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
| | - Walid Ben Ali
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada.,Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
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29
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Alternative Access for Transcatheter Aortic Valve Replacement: A Comprehensive Review. Interv Cardiol Clin 2021; 10:505-517. [PMID: 34593113 DOI: 10.1016/j.iccl.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Transfemoral is the most widely used access to perform transcatheter aortic valve replacement (TAVR). However, alternative access is needed in up to 21% of patients with TAVR because of a myriad of factors. The authors provide a comprehensive review on alternative access for TAVR, discussing the relevant data and providing the pros and cons of each access route.
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30
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Percutaneous transAXillary access for endovascular aortic procedures in the multicenter international PAXA registry. J Vasc Surg 2021; 75:868-876.e3. [PMID: 34600031 DOI: 10.1016/j.jvs.2021.08.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches. METHODS A physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique. RESULTS Three hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively. CONCLUSIONS Percutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.
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31
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Jiménez-Quevedo P, Nombela-Franco L, Muñoz-García E, del Valle-Fernández R, Trillo R, de la Torre Hernández JM, Salido L, Elizaga J, Ojeda S, Sánchez Gila J, García del Blanco B, Berenguer A, Lasa-Larraya G, Urbano Carrillo C, Albarrán A, Ruiz-Salmerón R, Moreu J, Gheorghe L, Arzamendi D, Yanes-Bowden G, Díaz J, Pérez-Moreiras I, Artaiz M, Vaquerizo B, Cruz-González I, Ruiz-Quevedo V, Blanco-Mata R, Baz JA, Villa M, Ortiz de Salazar Á, Tascón-Quevedo V, Casellas S, Moreno R. Resultados clínicos tempranos tras el implante percutáneo de válvula aórtica por acceso transaxilar comparado con el acceso transfemoral. Datos del registro español de TAVI. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2021.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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32
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Morozowich ST, Sell-Dottin KA, Crestanello JA, Ramakrishna H. Transcarotid Versus Transaxillary/Subclavian Transcatheter Aortic Valve Replacement (TAVR): Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 36:1771-1776. [PMID: 34083097 DOI: 10.1053/j.jvca.2021.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/11/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has revolutionized the percutaneous management of valvular heart disease and has evolved to progressively minimalist techniques over the past decade. This review discusses the impact of minimalist TAVR, explores the alternative approaches when transfemoral (TF) TAVR is not possible, and analyzes the current outcomes of transcarotid (TC) versus transaxillary/subclavian (TAx) TAVR, which are the two leading nonfemoral (NF) approaches emerging as the preferred alternatives to TF TAVR.
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Affiliation(s)
- Steven T Morozowich
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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33
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Tagliari AP, Saadi RP, Ferrari E, Taramasso M, Saadi EK. The Role of the Axillary Artery as a Second Access Choice in TAVI Procedures. Braz J Cardiovasc Surg 2021; 36:237-243. [PMID: 33355810 PMCID: PMC8163263 DOI: 10.21470/1678-9741-2020-0343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.
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Affiliation(s)
- Ana Paula Tagliari
- Department of Cardiac Surgery, University Hospital of Zurich, University Heart Center Zurich, Zurich, Switzerland.,Department of Cardiovascular Surgery, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil.,Postgraduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Petersen Saadi
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil.,Department of Cardiovascular Surgery, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Enrico Ferrari
- Department of Cardiac Surgery, University Hospital of Zurich, University Heart Center Zurich, Zurich, Switzerland.,Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
| | - Maurizio Taramasso
- Department of Cardiac Surgery, University Hospital of Zurich, University Heart Center Zurich, Zurich, Switzerland
| | - Eduardo Keller Saadi
- Department of Cardiovascular Surgery, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil.,Department of Cardiovascular Surgery, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
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34
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Mitsis A, Eftychiou C, Eteokleous N, Papadopoulos K, Zittis I, Avraamides P. Current Trends in TAVI Access. Curr Probl Cardiol 2021; 46:100844. [PMID: 33994035 DOI: 10.1016/j.cpcardiol.2021.100844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Andreas Mitsis
- Cardiology Department, Nicosia General Hospital, 2029, Nicosia, Cyprus.
| | | | | | | | - Ioannis Zittis
- Cardiology Department, Nicosia General Hospital, 2029, Nicosia, Cyprus
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35
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Jones BM, Kumar V, Chiu ST, Korngold E, Hodson RW, Spinelli KJ, Kirker EB. Comparable Outcomes for Transcarotid and Transfemoral Transcatheter Aortic Valve Replacement at a High Volume US Center. Semin Thorac Cardiovasc Surg 2021; 34:467-474. [PMID: 33713830 DOI: 10.1053/j.semtcvs.2021.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 11/11/2022]
Abstract
With continued growth of transcatheter aortic valve replacement (TAVR), safe alternative access remains important for patients without adequate transfemoral (TF) access. Registry-based outcomes with transcarotid (TC) TAVR are favorable compared to transapical or transaxillary/subclavian, but TC vs TF comparisons have not been made. Our objective was to compare outcomes between TF and TC access routes for TAVR at a high-volume United States center. Methods: We retrospectively evaluated all TF and TC TAVR procedures from June 11, 2014 (first TC case) through December 31, 2019. The primary outcomes were 30-day stroke and 30-day mortality. Secondary outcomes were 1-year stroke, 1-year survival, and 30-day and 1-year life-threatening/major bleeding, vascular complications, and myocardial infarction. Propensity score weighted (PSW) models were used to compare risk-adjusted TF and TC outcomes. Of 1,465 TAVR procedures, 1319 (90%) were TF and 146 (10%) were TC. Procedure time and length of stay did not differ between groups. Unadjusted 30-day stroke (TF = 2.0%, TC = 2.7%, P = 0.536) and mortality (TF = 2.1%, TC = 2.7%, P = 0.629) were similar between groups. PSW 30-day stroke (odds ratio (OR) (95% confidence interval (CI)) = 0.8 (0.2-2.8)) and mortality (OR (95% CI) = 0.8 (0.2-3.0)) were similar between groups. Unadjusted and PSW 30-day major/life threatening bleeding, major vascular complications, and myocardial infarction did not differ between groups. Survival at one year was 90% (88%-92%) for TF patients and 87% (81%-93%) for TC patients (unadjusted P = 0.28, PSW hazard ratio = 1.0 (0.6-1.7)). Transcarotid TAVR is associated with similar outcomes compared to transfemoral TAVR at an experienced, high-volume center.
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Affiliation(s)
- Brandon M Jones
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon.
| | - Vishesh Kumar
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon
| | - Shih Ting Chiu
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon
| | - Ethan Korngold
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon
| | - Robert W Hodson
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon
| | - Kateri J Spinelli
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon
| | - Eric B Kirker
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, , Portland, Oregon
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Utility of the minimum-incision transsubclavian approach for transcatheter aortic valve replacement on clinical outcomes in patients with small vessel anatomy. J Cardiol 2021; 78:31-36. [PMID: 33637407 DOI: 10.1016/j.jjcc.2021.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/06/2020] [Accepted: 12/24/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal approach for patients undergoing transcatheter aortic valve replacement (TAVR), who are contraindicated for a transfemoral (TF) approach, is still controversial. The present study aimed to evaluate the utility of the TAVR via a subclavian artery with a small diameter, by minimal incision and a double Z suture hemostasis technique using 18 Fr DrySeal Flex sheath, namely minimum-incision transsubclavian TAVR (MITS-TAVR), in patients contraindicated for the TF approach. METHODS We included consecutive patients who underwent the MITS-TAVR (MITS group; n = 21) and TF-TAVR (TF group; n = 81) using the CoreValve Evolut R/PRO valves and examined the incidence of in-hospital adverse events and post-discharge mortality between the two groups. RESULTS The mean body surface area was significantly smaller in the MITS group (1.33 ± 0.04 vs. 1.43 ± 0.02 m2; p = 0.045). The minimal lumen diameter of the femoral artery was significantly smaller in the MITS group (5.01 vs. 6.43 mm; p < 0.01). The lumen diameter of the left subclavian artery (LSA) in the MITS group was 4.97 ± 0.14 mm. The duration of the TAVR procedure to discharge was not significantly different (9.7 ± 2.0 days vs. 13.2 ± 1.0 days; p = 0.239). We did not experience in-hospital death in both groups, and no significant differences were observed in the incidence of major adverse cardiac and cerebrovascular events between the two groups. The post-discharge survival rate was not significantly different between the groups (at 2-year; MITS group vs. TF group = 91.0% vs. 89.0%; p = 0.725). CONCLUSIONS The MITS-TAVR using 18 Fr Dryseal Flex sheath was safe and effective and might be a promising alternative approach even in patients with a small body and small LSA diameter, who are contraindicated to the TF approach.
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Amer MR, Mosleh W, Megaly M, Shah T, Ooi YS, McKay RG. Outcomes of transcarotid versus trans-subclavian transcatheter aortic valve replacement: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 33:20-25. [DOI: 10.1016/j.carrev.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 11/17/2022]
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Wilkins B, Bielauskas G, Costa G, Fukutomi M, Søndergaard L, De Backer O. Percutaneous Transaxillary versus Surgically-Assisted Transsubclavian TAVR: A Single Center Experience. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2020.1849882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Amat-Santos IJ, Santos-Martínez S, Conradi L, Taramasso M, Poli A, Romaguera R, Pan M, Bagur R, Del Valle R, Nombela-Franco L, Bhadra OD, Aparisi Á, Redondo A, Gutiérrez H, Gómez I, Roman JAS. Transaxillary transcatheter ACURATE neo aortic valve implantation - The TRANSAX multicenter study. Catheter Cardiovasc Interv 2020; 98:E291-E298. [PMID: 33315296 DOI: 10.1002/ccd.29423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/25/2020] [Accepted: 11/29/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) via transaxillary (TAx) approach with ACURATE neo valve is an off-label procedure. Our aim was to gather information on ACURATE neo cases implanted via TAx approach and report major outcomes. METHODS AND RESULTS The TRANSAX Study (NCT04274751) retrospectively gathered patients from nine centres in Europe and North America treated with ACURATE neo valve through TAx approach up to May/2019. Follow up was pre-specified at 1-year and was obtained for all patients. A total of 75 patients (79 ± 10 years; 32% women) were included. Left axillary (72%) and conscious sedation (95.2%) were the most common setting. Risk scores were higher when right axillary artery and surgical cut-down were selected. Severe complications including valve embolization, coronary obstruction, annulus rupture, and procedural mortality did not occur. Cardiac tamponade occurred in two cases (2.7%) with one requiring conversion to open surgery (1.3%). Bail-out stenting and surgical vascular repair were required in 7 (9.3%) and 3 (4%) cases, respectively. The need for new permanent pacemaker was 8%. Procedural success (96%), in-hospital (2.7%), and 1-year mortality (8%) were comparable in all settings. Only one case (1.3%) complicated with cerebrovascular event and one (1.3%) presented moderate aortic regurgitation before discharge. CONCLUSIONS TAx TAVR procedures with the ACURATE neo valve were presented high success rate and low in-hospital and 1-year mortality.
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Affiliation(s)
| | | | - Lenard Conradi
- Department of Cardiovascular Surgery, Universitäres Herz und Gefäßzentrum, Hamburg, Germany
| | - Maurizio Taramasso
- Department of Cardiovascular Surgery, UniversitätsSpital, Zürich, Switzerland
| | - Arnaldo Poli
- Interventional Cardiology Department, ASST Ovest Milanese- Ospedale di Legnano, Milan, Italy
| | - Rafael Romaguera
- Cardiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Manuel Pan
- Cardiology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Rodrigo Bagur
- Cardiology Division, London Health Sciences Centre, Department of Medicine, Western University, London, Ontario, Canada
| | - Raquel Del Valle
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Luis Nombela-Franco
- Cardiology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Oliver D Bhadra
- Department of Cardiovascular Surgery, Universitäres Herz und Gefäßzentrum, Hamburg, Germany
| | - Álvaro Aparisi
- CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
| | | | | | - Itziar Gómez
- CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
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Ooms JF, Van Wiechen MP, Hokken TW, Goudzwaard J, De Ronde-Tillmans MJ, Daemen J, Mattace-Raso F, De Jaegere PP, Van Mieghem NM. Simplified Trans-Axillary Aortic Valve Replacement Under Local Anesthesia - A Single-Center Early Experience. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:7-13. [PMID: 33281073 DOI: 10.1016/j.carrev.2020.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The axillary artery is an alternative route for patients with comorbidities and unfavorable femoral arteries who need transcatheter aortic valve replacement (TAVR). Simplified trans-axillary transcatheter aortic valve replacement (TAx-TAVR) implies a completely percutaneous approach under local anesthesia and arteriotomy closure with vascular closure techniques. Herein, we report on early experience with simplified TAx-TAVR under local anesthesia. METHODS We enrolled all consecutive patients who underwent simplified TAx-TAVR in our center. Main study parameter was the incidence of axillary access related major vascular complications within 30 days. Secondary parameters included a composite early safety endpoint, axillary access-site related vascular/bleeding complications and short-term mortality. Post TAVR axillary stent patency was evaluated during follow-up by CT-analysis. RESULTS Between July 2018 and April 2020, Tax-TAVR was attempted in 35 patients with a mean age of 79 years. Local anesthesia and conscious sedation were used in 91.4% (n = 32) and 8.6% (n = 3) respectively. A covered stent was needed for complete axillary hemostasis in 44.1% (n = 15). Device success was achieved in 91.2% (n = 31/34). The 30-day axillary artery major vascular and ≥major bleeding complication rates were 14% (n = 5) and 11% (n = 4). The early safety endpoint was reached in 22.9% (n = 8). Mortality rates at 30 days and six months were 2.9% and 11.6%. Computed tomography (CT) confirmed axillary stent patency during follow-up in 82% (n = 9/11). CONCLUSIONS In patients with high/prohibitive surgical risk and unsuitable femoral access, simplified TAx-TAVR under local anesthesia offers a valuable alternative for transfemoral TAVR but requires advanced access site management techniques including covered stents. Our data suggest an unmet clinical need for dedicated TAx closure devices.
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Affiliation(s)
- Joris F Ooms
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maarten P Van Wiechen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Thijmen W Hokken
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeannette Goudzwaard
- Section of Geriatrics, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marjo J De Ronde-Tillmans
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Francesco Mattace-Raso
- Section of Geriatrics, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter P De Jaegere
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Access routes for transcatheter aortic valve implantation - my way or the "easiest" way. Rev Port Cardiol 2020; 39:719-721. [PMID: 33293223 DOI: 10.1016/j.repc.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Fiarresga A. Access routes for transcatheter aortic valve implantation – my way or the “easiest” way. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Debry N, Trimech TR, Gandet T, Vincent F, Hysi I, Delhaye C, Cayla G, Koussa M, Juthier F, Leclercq F, Pécheux M, Ghostine S, Labreuche J, Modine T, Van Belle E. Transaxillary compared with transcarotid access for TAVR: a propensity-matched comparison from a French multicentre registry. EUROINTERVENTION 2020; 16:842-849. [DOI: 10.4244/eij-d-20-00117] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kanei Y, Qureshi W, Kaur N, Walker J, Kakouros N. The Safety and Efficacy of a Minimalist Approach for Percutaneous Transaxillary Transcatheter Aortic Valve Replacement (TAVR). STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2020. [DOI: 10.1080/24748706.2020.1825888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Yumiko Kanei
- Department of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Department of Surgery, Cardiac Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Trani C, Aurigemma C, Romagnoli E, Burzotta F. Percu-Ax aortic valve implantation with a double arm approach: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33204992 PMCID: PMC7649516 DOI: 10.1093/ehjcr/ytaa225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/03/2020] [Accepted: 06/24/2020] [Indexed: 12/05/2022]
Abstract
Background Transaxillary route for structural and coronary percutaneous interventions represents a valid alternative access in patients with obstructive peripheral disease. Nevertheless, its widespread use is limited by a less manageable haemostasis procedure. Case summary In this case, we describe a minimalistic high-risk transcatheter aortic valve implantation (TAVI) procedure (TAVI Score 6.42%) conducted with a double arm approach (radial and axillary accesses) in an 88-year-old patient with severe aortic stenosis and multiple co-morbidities preventing both surgical (Society of Thoracic Surgeons mortality 7.9%) and percutaneous transfemoral approach (extensive peripheral artery disease). We also described the successful management of a complicated transaxillary haemostasis with this technique. Discussion In our cases, a minimalist double-arm approach was successfully used for TAVI procedure as an alternative to transfemoral approach assuring effective and safe management of vascular access haemostasis.
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Affiliation(s)
- Carlo Trani
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Enrico Romagnoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous
large‐bore
axillary access is a safe alternative to surgical approach: A systematic review. Catheter Cardiovasc Interv 2020; 96:1481-1488. [DOI: 10.1002/ccd.29273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/30/2020] [Accepted: 09/01/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Geoffrey Southmayd
- Division of Cardiology Emory University School of Medicine Atlanta Georgia
| | - Azizul Hoque
- Division of Cardiology Emory University School of Medicine Atlanta Georgia
| | - Amir Kaki
- Division of Cardiology Ascension St. John Hospital Detroit Michigan
| | - Rajiv Tayal
- Division of Cardiology RWJ Barnabas Health, Newark Beth Israel Medical Center Newark New Jersey
| | - S. Tanveer Rab
- Division of Cardiology Emory University School of Medicine Atlanta Georgia
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Zhan Y, Toomey N, Ortoleva J, Kawabori M, Weintraub A, Chen FY. Safety and efficacy of transaxillary transcatheter aortic valve replacement using a current-generation balloon-expandable valve. J Cardiothorac Surg 2020; 15:244. [PMID: 32912309 PMCID: PMC7488327 DOI: 10.1186/s13019-020-01291-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/03/2020] [Indexed: 11/17/2022] Open
Abstract
Background Transaxillary access (TAx) has shown promise as an excellent alternative TAVR option, but data on the Edwards SAPIEN 3 in TAx-TAVR is limited. We sought to study the safety and efficacy of TAx-TAVR using this current-generation balloon-expandable valve. Methods A retrospective study of our first 24 TAx and 20 transthoracic (TT) TAVR patients treated with the SAPIEN 3 valve was performed, and the patients’ preoperative characteristics, procedural outcomes, and clinical outcomes were compared to our first 100 transfemoral (TF) patients using the SAPIEN 3 device. Results There were no statistical differences observed for outcomes between the TAx and TF groups, despite the TAx patients having more comorbidities (STS-PROM 11.3 ± 7.6 versus 7.3 ± 5.2, p = 0.042). In addition, no significant difference was found in the fluoroscopy time and contrast amount between the two groups. The patients’ baseline characteristics were similar between the TAx and TT groups. Their procedural and clinical outcomes were comparable, but there was a trend towards lower incidence of acute kidney injury (13.0% versus 23.5%), new-onset atrial fibrillation (5.6% versus 33.3%), shorter median length of stay postoperatively (4 versus 6 days), fewer discharges to rehabilitation (16.7% versus 35.0%), and a lower rate of readmission within 30-days (8.3% versus 35.0%), all favoring TAx access. Conclusions TAx-TAVR with the SAPIEN 3 valve is a safe alternative to TF access. It offers advantages of improved recovery over TT access, and appears to be a superior alternative-access option for TAVR. TAx access could be preferred when TF access is not feasible.
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Affiliation(s)
- Yong Zhan
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, #266, Boston, MA, 02111, USA.
| | - Nicholas Toomey
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, #266, Boston, MA, 02111, USA
| | - Jamel Ortoleva
- Division of Cardiac Anesthesia, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Masashi Kawabori
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, #266, Boston, MA, 02111, USA
| | - Andrew Weintraub
- Division of Cardiology, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Frederick Y Chen
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, #266, Boston, MA, 02111, USA
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Morello A, Corcione N, Ferraro P, Cimmino M, Pepe M, Cassese M, Frati G, Biondi-Zoccai G, Giordano A. The best way to transcatheter aortic valve implantation: From standard to new approaches. Int J Cardiol 2020; 322:86-94. [PMID: 32814109 DOI: 10.1016/j.ijcard.2020.08.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/07/2020] [Accepted: 08/07/2020] [Indexed: 02/08/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is a safe and beneficial treatment for patients with severe symptomatic aortic stenosis at high and intermediate surgical risk. The safety of the procedure continues to improve thanks to more refined procedural approaches and devices but, also and above all, to the accrual of the procedural knowledge and expertise by the operators. The diversification of the approaches and the possibility to tailor the treatment on the individual needs and anatomical features of the patients allows a rapid learning curve in the management of even complications. Indeed, there are several approaches with which TAVI can be carried out: transfemoral arterial, subclavian, transcarotid, transaortic, transaxillary, transapical, and through right anterior thoracotomy. Although transfemoral venous TAVI is less common, it has already have been carried out using caval-aortic punctures. This field is rapidly evolving, and it will be of paramount importance for interventional cardiologists and cardiothoracic surgeons to keep up to date with further developments. This review intends to give an in-depth and update overview of both conventional and innovative TAVI approaches, with the scope to highlight the relevant advantages, major disadvantages, safety aspects and techniques.
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Affiliation(s)
- Alberto Morello
- Unità Operativa di Interventistica Cardiovascolare, Pineta Grande Hospital, Castel Volturno, Italy.
| | - Nicola Corcione
- Unità Operativa di Interventistica Cardiovascolare, Pineta Grande Hospital, Castel Volturno, Italy
| | - Paolo Ferraro
- Unità Operativa di Emodinamica, Santa Lucia Hospital, San Giuseppe Vesuviano, Italy
| | - Michele Cimmino
- Unità Operativa di Emodinamica, Santa Lucia Hospital, San Giuseppe Vesuviano, Italy
| | - Martino Pepe
- Division of Cardiology, Department of Emergency and OrganTransplantation, University of Bari, Bari, Italy
| | - Mauro Cassese
- Heart Surgery Department, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; IRCCS NEUROMED, Pozzilli, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Pineta Grande Hospital, Castel Volturno, Italy
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Efficacy of Manual Hemostasis for Percutaneous Axillary Artery Intra-Aortic Balloon Pump Removal. J Interv Cardiol 2020; 2020:8375878. [PMID: 32774189 PMCID: PMC7399779 DOI: 10.1155/2020/8375878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/04/2020] [Indexed: 11/18/2022] Open
Abstract
Background The prevalence of peripheral vascular disease has led to the re-emergence of percutaneous axillary vascular access as a suitable alternative access site to femoral artery. We sought to investigate the efficacy and safety of manual hemostasis in the axillary artery. Methods Data were collected from a prospective internal registry of patients who had a Maquet® (Rastatt, Germany) Mega 50 cc intra-aortic balloon pumps (IABP) placed in the axillary artery position. They were anticoagulated with weight-based intravenous heparin to maintain an activated partial thromboplastin time (aPTT) of 50-80 seconds. Anticoagulation was discontinued 2 hours prior to the device explantation. Manual compression was used to achieve the hemostasis of the axillary artery. Vascular and bleeding complications attributable to manual hemostasis were classified based on the Valve Academic Research Consortium-2 (VARC-2) and Bleeding Academic Research Consortium-2 (BARC-2) classifications, respectively. Results 29 of 46 patients (63%) achieved axillary artery homeostasis via manual compression. The median duration of IABP implantation was 12 days (range 1-54 days). Median compression time was 20 minutes (range 5-60 minutes). There were no major vascular or bleeding complications as defined by the VARC-2 and BARC-2 criteria, respectively. Conclusion Manual compression of the axillary artery appears to be an effective and safe method for achieving hemostasis. Large prospective randomized control trials may be needed to corroborate these findings.
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Rück A, Eriksson D, Verouhis D, Saleh N, Linder R, Corbascio M, Settergren M. Percutaneous access and closure using the MANTA vascular closure device in transaxillary transcatheter aortic valve implantation. EUROINTERVENTION 2020; 16:266-268. [PMID: 31793886 DOI: 10.4244/eij-d-19-00809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Andreas Rück
- Cardiovascular Theme, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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