Transcaval Versus Transaxillary TAVR in Contemporary Practice: A Propensity-Weighted Analysis

Robert J Lederman; Vasilis C Babaliaros; John C Lisko; Toby Rogers; Paul Mahoney; Jason R Foerst; Jeremiah P Depta; Kamran I Muhammad; James M McCabe; Andrei Pop; Jaffar M Khan; Christopher G Bruce; Giorgio A Medranda; Jane W Wei; Jose N Binongo; Adam B Greenbaum

doi:10.1016/j.jcin.2022.03.014

Transcaval Versus Transaxillary TAVR in Contemporary Practice: A Propensity-Weighted Analysis

JACC Cardiovasc Interv. 2022 May 9;15(9):965-975. doi: 10.1016/j.jcin.2022.03.014.

Authors

Robert J Lederman¹, Vasilis C Babaliaros², John C Lisko², Toby Rogers³, Paul Mahoney⁴, Jason R Foerst⁵, Jeremiah P Depta⁶, Kamran I Muhammad⁷, James M McCabe⁸, Andrei Pop⁹, Jaffar M Khan¹⁰, Christopher G Bruce¹⁰, Giorgio A Medranda¹¹, Jane W Wei¹², Jose N Binongo¹², Adam B Greenbaum¹³

Affiliations

¹ Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA. Electronic address: lederman@nih.gov.
² Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA.
³ 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.
⁴ Division of Cardiology, The Sentara Heart Center, Norfolk, Virginia, USA.
⁵ Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA.
⁶ Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, New York, USA.
⁷ Oklahoma Heart Institute, Tulsa, Oklahoma, USA.
⁸ Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA.
⁹ AMITA Health Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA.
¹⁰ Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
¹¹ Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
¹² Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
¹³ Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA. Electronic address: https://twitter.com/AdamGreenbaumMD.

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.

Keywords: alternative access; nonfemoral access; percutaneous access; subclavian access; transaxillary access; transcaval access.

Published by Elsevier Inc.

Publication types

Research Support, Non-U.S. Gov't
Research Support, N.I.H., Intramural

MeSH terms

Aortic Valve / diagnostic imaging
Aortic Valve / surgery
Aortic Valve Stenosis* / diagnostic imaging
Aortic Valve Stenosis* / surgery
Humans
Ischemic Attack, Transient*
Registries
Risk Factors
Stroke*
Transcatheter Aortic Valve Replacement*
Treatment Outcome
United States

Abstract

Publication types

MeSH terms

Grants and funding