Eastern Cardiothoracic Surgical Society

Alternate Approaches to Femoral Transcatheter Aortic Valve Replacement (TAVR) in High-risk Patients with Limited Peripheral Access or Challenging Aorta
Mark A. Groh, William B. Abernethy, Joshua P. Leitner, Gerard L. Champsaur. Mission Hospital, Asheville, NC USA.

Objective: As TAVR volumes increase, reducing risk for patients with access, aortic, or implantation issues is critical to improving implant results. We are increasingly seeking alternate approaches for TAVR and we are assessing in this work their potential clinical benefits.

Methods: Between 2012 and 2015, a consecutive series of 145 patients underwent a TAVR in our Institution. All data were entered prospectively in our local ACC/STS/TVT database and retrieved for analysis. The types of procedures were 8 cases of trans-apical (TA), 62 cases of trans-femoral (TF), and 75 cases of trans-aortic (TAo) approaches, including a trans-innominate artery route (TI) in 23 recent cases.

Results: Demographics and procedure data are displayed in Table SA2-1 and Figure SA2-1 for the two approaches (TAo vs. TF) since there were no significant differences between original TAo and recent TI cases. TAo was performed in higher risk patients, with a more severe mean STS risk score and more frequent comorbidities although ages were not different. TAo procedures were shorter than TF ones and patients received smaller contrast volumes, radiation doses, and shorter fluoroscopy times. There were 8 strokes in the whole series, 5 in TF patients and 3 after TAo, and 2 TIAs, one in each group. Pre-discharge mortality (4%) was equivalent in both groups.

Conclusions: TAo and TI approaches have led to similar short-term outcomes in a higher risk population than our TF cases. Alternate access via the innominate artery is increasingly used at our Institution as it provides reliable easy access with minimal sternal disruption.

Table 1 – Peri-operative Variables. Data Expressed as Mean ±SD or Frequency and (%).
Variable TF, n= 62 TAo, n= 75 p value
Age 84.9 ±7.4 83.9 ±7.5 0.481
Pre-op. Hemodialysis 0.0% 7 ±0.3% 0.038
STS risk Score, % 6.5 ±2.4% 8.9 ±6.1% 0.006
Left Main Disease 1 (1.6) 18 (25) 0.010
Procedure duration, H:mn 2:16 ±1:04 1:50 ±0:47 0.006
Device success 0.85 ±0.36 0.95 ±0.33 0.063
Contrast Volume, ml 114.9 ±47.8 70.99 ±33.15 <0.001
Fluoro time, mn:sec 19:4 ±6:5 10:2 ±18:5 <0.001
Fluoro dose, PKA 1060.5 ±864.8 628.9 ±613.3 0.001

Figure 1 - Number of Cases Per Procedure Per Year