Transcarotid Transcatheter Aortic Valve Replacement

Transcarotid versus transthoracic transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on Transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes.

METHODS

We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2.

RESULTS

Sixteen observational studies on Transcarotid TAVR were included in the analysis; 4 studies compared 180 TC-TAVR patients vs 524 TT-TAVR patients. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TT-TAVR patients, the mean age and STS score were 79.7 years and 8.7 respectively. TC-TAVR patients had lower 30-day MACE [7.8 % vs 13.7 %; OR 0.54 (95 % CI 0.29-0.99, P = 0.05)] and major or life-threatening bleeding [4.0 % vs 14.2 %; OR 0.25 (95 % CI 0.09-0.67, P = 0.006)]. There was no significant difference in 30-day: mortality [5.0 % vs 8.6 %; OR 0.61 (95 % CI 0.29-1.30, P = 0.20)], stroke or transient ischemic attack [2.8 % vs 4.0 %; OR 0.65 (95 % CI 0.25-1.73, P = 0.39)] and moderate or severe aortic valve regurgitation [5.0 % vs 4.6 %; OR 1.14. (95 % CI 0.52-2.52, P = 0.75)]. There was a trend towards fewer major vascular complications in TC-TAVR [3.0 % vs 7.8 %; OR 0.42 (95 % CI 0.16-1.12, P = 0.08)].

CONCLUSION

Compared with transthoracic TAVR, TC-TAVR patients had lower odds of 30-day MACE and life-threatening bleeding and no differences in 30-day mortality, stroke or TIA, aortic valve regurgitation.

Transcarotid versus transfemoral transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

In the 2021 Transcatheter Valve Therapy (TVT) registry, 8.9 % of patients underwent TAVR via access sites other than the femoral artery. Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes.

METHODS

We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2.

RESULTS

Sixteen observational studies on transcarotid TAVR were included in the analysis; 4 studies compared TC-TAVR vs TF-TAVR. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TF-TAVR patients, mean age and STS score were 81.2 years and 6.5 respectively. There was no difference between patients undergoing TC-TAVR and TF-TAVR in the following 30-day outcomes: MACE [8.4 % vs 6.7 %; OR 1.32 (95 % CI 0.71-2.46 p = 0.38) I2 = 0 %], mortality [5.6 % vs 4.0 %; OR 0.42 (95 % CI 0.60-3.37, P = 0.42) I2 = 0 %] and stroke [0.7 % vs 2.3 %; OR 0.49 (95 % CI 0.09-2.56, P = 0.40) I2 = 0 %]. There was no difference in 30-day major vascular complications [0.7 % vs 3 %; OR 0.55 (95 % CI 0.06-5.29, P = 0.61) I2 = 39 %], major bleeding [0.7 % vs 3.8 %; OR 0.39 (95 % CI 0.09-1.67, P = 0.21) I2 = 0 %], and moderate or severe aortic valve regurgitation [8.6 % vs 9.9 %; OR 0.89 (95 % CI 0.48-1.65, P = 0.72) I2 = 0 %].

CONCLUSION

There are no significant differences in mortality, stroke MACE and major or life-threatening bleeding or vascular complications when TC-TAVR is compared to TF-TAVR approaches.

Carotid Access for Aortic Interventions: Genius or Madness?

The endovascular-first approach remains is omnipresent ubiquitous amongst in the vascular community today. However, several key issues have ensued remain, one of which involves the choice of vessel site. Although the transfemoral route is the first-line approach has been established as first-line approach in endovascular interventions of the aorta (endovascular aortic repair [EVAR], thoracic endovascular aortic repair [TEVAR], and transcatheter aortic valve implantation [TAVI]), there remains a select some group of patients who are contraindicated for the aforementioned this as well as for alternatives vessel routes such as the transapical approach. The carotid artery, first used in aortic aneurysm repair, is potential alternative for these patients. Emerging evidence appears to support this relatively unpopular approach in EVAR, TEVAR and TAVI. Sporadic case reports and series have reported the transcarotid approach for EVAR and TEVAR, and collectively show relatively low rates of mortality and neurological complications. For TAVI, the carotid artery appears to be a safe and effective route of access compared to the transapical and even the transfemoral approach. However, technical aspects have not been ironed out; there are procedural variations, for example, in type of anaesthesia used, intraoperative neurological monitoring and choice of common carotid artery. The overall quality of evidence is poor, since the majority of it consists of case reports, and retrospective and prospective cohort studies. Although a randomised controlled trial (RCT) is needed to compare the transcarotid against the transfemoral approach, this is unlikely to take place because of ethical considerations. Therefore, the authors recommend future research to consider cohort studies with adequately powered sample sizes to establish any firm conclusions. However, as transcarotid procedures are performed infrequently, most institutions will have relatively small sample sizes. Therefore, it is recommended that collaborative efforts are undertaken to increase the overall sample size in the cohort analysis.