Comparison of Transfemoral versus Transsubclavian/Transaxillary access for transcatheter aortic valve replacement: A systematic review and meta-analysis

Right transaxillary transcatheter aortic valve replacement is comparable to left despite challenges

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.

An Updated Comprehensive Review of Existing Transcatheter Aortic Valve Replacement Access

For the past 20 years, transcatheter aortic valve replacement (TAVR) has been the treatment of choice for symptomatic aortic stenosis. The transfemoral (TF) access is considered the gold standard approach for TAVR. However, TF-TAVR cannot be performed in some patients; thus, alternative accesses are required. Our review paper generalises the TAVR accesses currently available, including the transapical, transaortic, trans-subclavian/axillary, transcarotid, transcaval, and suprasternal approaches. Their advantages and disadvantages have been analysed. Since there is no standard recommendation for an alternative approach, access selection depends on the expertise of the local cardiac team, patient characteristics, and access properties. Each TAVR centre is recommended to master a minimum of one non-TF access alternative. Of note, more evidence is required to delve into the clinical outcomes of each approach, at both early and long-term (Figure 1).

Survival outcomes of TAVR and self-expanding versus balloon-expandable valves in patients with advanced cardiac dysfunction

AIMS

There is a growing body of literature on long-term outcomes post-transcatheter aortic valve replacement (TAVR), but to our knowledge, few research have focused on patients with advanced cardiac dysfunction. This challenging category of patients was excluded from the Partner 3 clinical trial. There are no data to guide the choice of valve type in patients with severely depressed ejection fraction. This study evaluates the safety, efficacy, and outcomes of TAVR in patients with severe aortic stenosis and left ventricular ejection fraction (LVEF) ≤ 35%. It compares post-TAVR survival outcomes with self-expanding (SEV) versus balloon-expandable (BEV) valves in the context of cardiac dysfunction.

METHODS AND RESULTS

A retrospective cohort was conducted on 977 patients who underwent TAVR at Toulouse University Hospital between January 2016 and December 2020. The study population included two groups: LVEF ≤ 35% (N = 157) and LVEF ≥ 50% (N = 820). The group of LVEF ≤ 35% was divided into two subgroups according to the type of implanted device: self-expanding (N = 66) versus balloon-expandable (N = 91). The living status of each of study's participants was observed in December 2022. Patients with low ejection fraction were younger (82 vs. 84.6 years) and commonly males (71.3% vs. 45.6%). Procedural success was almost 98% in both study groups (97.5% vs. 97.9%). The prevalence of all in-hospital post-TAVR complications [acute kidney injury (3.8% vs. 2.2%), major bleeding events (2.5% vs. 3.2%), stroke (1.3% vs. 1.6%), pacemaker implantation (10.2% vs. 10.7%), major vascular complication (4.5% vs. 4.5%), new onset atrial fibrillation (3.2% vs. 3.4%), and in-hospital death (3.2% vs. 2.8%)] were similar between groups (LVEF ≤ 35% vs. LVEF ≥ 50%). No difference in long-term survival has been revealed over 3.4 years (P = 0.268). In patients with LVEF ≤ 35%, except for post-TAVR mean aortic gradient (7.8 ± 4.2 vs. 10.2 ± 3.6), baseline and procedural characteristics were comparable between SEV versus BEV subgroups. An early improvement in LVEF (from 29.2 ± 5.5 to 37.4 ± 10.8) was observed. In patients with LVEF ≤ 35%, the all-cause mortality rate was significantly higher in BEV than that in SEV subgroups, respectively (40.7% vs. 22.7%, P = 0.018). Kaplan-Meier curve showed better survival outcomes after SEV implantation (P = 0.032). A Cox regression identified BEV as independent predictor of mortality [HR = 3.276, 95% CI (1.520-7.060), P = 0.002].

CONCLUSIONS

In the setting of low LVEF, TAVR remains a safe and effective procedure not associated with an increased risk of complications and mortality. SEV implantation may likely result in superior survival outcomes in patients with advanced cardiac dysfunction.

Computed tomography derived anatomical predictors of vascular access complications following transfemoral transcatheter aortic valve implantation: A systematic review

BACKGROUND

Vascular complications after percutaneous transfemoral transcatheter aortic valve implantation (TAVI) are associated with adverse clinical outcomes and remain a significant challenge.

AIMS

The purpose of this review is to synthesize the existing evidence regarding the iliofemoral artery features predictive of vascular complications after TAVI on pre-procedural contrast-enhanced multidetector computed tomography (MDCT).

METHODS

A systematic search was performed in Embase and Medline (Pubmed) databases. Studies of patients undergoing transfemoral TAVI with MDCT were included. Studies with only valve-in-valve TAVI, planned surgical intervention and those using fluoroscopic assessment were excluded. Data on study cohort, procedural characteristics and significant predictors of vascular complications were extracted.

RESULTS

We identified 23 original studies involving 8697 patients who underwent TAVI between 2006 and 2020. Of all patients, 8514 (97.9%) underwent percutaneous transfemoral-TAVI, of which 8068 (94.8%) had contrast-enhanced MDCT. The incidence of major vascular complications was 6.7 ± 4.1% and minor vascular complications 26.1 ± 7.8%. Significant independent predictors of major and minor complications related to vessel dimensions were common femoral artery depth (>54 mm), sheath-to-iliofemoral artery diameter ratio (>0.91-1.19), sheath-to-femoral artery diameter ratio (>1.03-1.45) and sheath-to-femoral artery area ratio (>1.35). Substantial iliofemoral vessel tortuosity predicted 2-5-fold higher vascular risk. Significant iliofemoral calcification predicted 2-5-fold higher risk. The iliac morphology score was the only hybrid scoring system with predictive value.

CONCLUSIONS

Independent iliofemoral predictors of access-site complications in TAVI were related to vessel size, depth, calcification and tortuosity. These should be considered when planning transfemoral TAVI and in the design of future risk prediction models.

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

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