Carotid ultrasound following transcarotid transcatheter aortic valve replacement

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Highlights

  • Peak systolic velocities of the carotid artery increase after TC-TAVR.

  • New carotid stenosis (>50%) were diagnosed in 4% of patients after TC-TAVR.

  • No adverse events related to these findings occurred.

Abstract

Background

Transcarotid (TC) is a common alternative access for transcatheter aortic valve replacement (TAVR) when the transfemoral route is not suitable. However, scarce data exist on systematic ultrasound (US) follow-up of these patients. This study aims to evaluate the safety of TC-TAVR using pre-and post-procedure carotid artery US assessment.

Methods

We performed an observational prospective study including 50 consecutive patients who underwent TC-TAVR that had a follow-up at our institution between September 2016 and July 2020.

Results

All patients had a carotid US examination at a median time of 13 months (IQR: 5–17) following the procedure. Thirty-six (71%) patients also had a US examination prior to the procedure. Mean pre-procedural access route common carotid artery (AR-CCA) peak systolic velocity (PSV) was 62.9 cm/s (SD:16.8) vs. 69.0 cm/s (SD: 53.4) in the contralateral CCA (CL-CCA), p = 0.562). There was a significant increase in post-procedural PSV values in the AR-CCA (30.3 cm/s (SD: 36.3), p < 0.001) but not in the CL-CCA (5.8 cm/s (SD: 51.7), p = 0.503). Two new carotid stenoses (4%) were diagnosed after the procedure. No baseline or procedural variables were associated with a higher increase in carotid flow velocities at follow-up. There were no cerebrovascular events related to these findings after a median follow-up of 29 months (IQR:13–33).

Conclusions

TC-TAVR was associated with a mild but significant increase in carotid flow velocities, with new significant (>50%) carotid stenosis diagnosed in 4% of patients. These findings were not associated with clinical events after a median follow-up of 2 years. Further studies are warranted.

Introduction

Transfemoral access is the preferred route for transcatheter aortic valve replacement (TAVR). However, this route is not suitable for numerous TAVR candidates [1]. Alternative non-transfemoral approaches including transcarotid (TC), transapical, transaortic, and transsubclavian/transaxillary are regularly used. TC is a well-described access route, allowing for a direct and short pathway to the aortic valve without thoracotomy. Nevertheless, some concerns remain regarding the risk of neurovascular events related to this access [2]. Also, scarce data exist about long-term imaging follow-up of the carotid artery following TC-TAVR [3], and no data comparing pre-and post-procedural carotid ultrasound (US) findings are available. Thus, the possibility of inducing some degree of vessel stenosis following the insertion of large-bore catheters through the carotid artery remains largely unknown. This study aimed to investigate the occurrence and degree of carotid artery stenosis evaluated by US following TC-TAVR.

Section snippets

Methods

This was an observational prospective study that included 50 consecutive patients who underwent TC-TAVR and had a planned follow-up at our institution from September 2016 to July 2020. Among 919 TAVR procedures, 226 (24.6%) patients had a TC access and 50 (22.1%) of them had a planned follow-up at our institution (Fig. 1). The study was conducted in accordance with the institutional ethics committee and the ethical guidelines of the 1975 Declaration of Helsinki, and all patients provided

Clinical characteristics of the population and outcomes

Baseline characteristics of the study population are shown in Table 1. Mean age was 78 years (SD: 7). Patients had multiple co-morbidities (42% diabetes mellitus, 62% chronic kidney disease, 42% previous heart surgery, 50% previous coronary percutaneous intervention). Valve deployment was successful in all cases without any conversion to open-heart surgery. One patient had an ischemic stroke ipsilateral to the access the day after the procedure with full neurological recovery at follow-up.

Discussion

This is the first descriptive study to provide detailed data of pre-and-post TC-TAVR US-Doppler assessment. Interestingly, PSV increased in both AR and CL-CCA after TAVR. Cammalleri et al. performed a carotid Doppler study in transfemoral TAVR recipients and showed similar results [7]. In this same study, a significant increase in PSV in the left ICA was observed after balloon aortic valvuloplasty and 10 min following THV deployment, suggesting that this augmentation was a marker of blood flow

Conclusion

In conclusion, TC-TAVR was associated with a significant increase in AR-CCA flow velocities. This augmentation was mild in most cases and not associated with clinical events after a median follow-up of 2 years. However, 4% of patients were diagnosed with new (asymptomatic) significant carotid stenosis as evaluated by Doppler-US examination. The clinical relevance of the observed variations of carotid flow velocities and new vessel stenosis must be assessed by further studies with a longer

Fundings

There was no specific funding for this study.

CRediT authorship contribution statement

Vassili Panagides: Conceptualization, Methodology, Software, Data curation, Formal analysis, Writing – original draft. Dimitri Kalavrouziotis: Validation, Investigation, Writing – review & editing. Eric Dumont: Validation, Investigation. Robert Delarochellière: Validation, Investigation. Jean-Michel Paradis: Validation, Investigation. Jules Mesnier: Validation, Investigation. Siamak Mohammadi: Conceptualization, Methodology, Writing – original draft. Josep Rodés-Cabau: Conceptualization,

Declaration of Competing Interest

Josep Rodés-Cabau has received institutional research grants from Edwards Lifesciences, Medtronic, and Boston Scientific. Vassili Panagides has received research grants from Medtronic, Boston Scientific, and Microport.

Acknowledgments

Dr. Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Disease Interventions.

Dr. Panagides has received a research grant from the “Mediterranean Academic Research and Studies in Cardiology” association (MARS Cardio).

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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation

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