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Transfemoral Versus Subclavian Access for Transcatheter Aortic Valve Replacement
Sarah Yousef, MD, James A. Brown, MD, Dustin Kliner, MD, Derek Serna-Gallegos, MD, Catalin Toma, MD, Saurabh Sanon, MD, Suresh Mulukutla, MD, Yisi Wang, MPH, Ibrahim Sultan, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objective: This study sought to compare outcomes of transcatheter aortic valve replacements (TAVRs) performed through subclavian access with those performed through transfemoral access.Methods: This was an observational study utilizing an institutional database of TAVRs from 2010 to 2018. All patients undergoing TAVR via transfemoral (TF-TAVR) or subclavian (SC-TAVR) approach were included in the study, while those who underwent TAVR through alternative access sites were excluded. The two groups were analyzed for differences in operative mortality and postoperative outcomes. Multivariable Cox analysis was performed to identify variables associated with long-term survival after TAVR.Results: Of the 1,095 patients identified, 133 patients underwent SC-TAVR and 962 patients underwent TF-TAVR. Patients who underwent SC-TAVR were older, more likely to have chronic lung disease and peripheral vascular disease and had a higher Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) (p<0.05). Operative mortality was similar between the TF-TAVR (2.7%) and the SC-TAVR group (3.8%). There were no significant differences in stroke, length of stay, 30-day readmission, blood transfusions, acute kidney injury, need for permanent pacemaker, paravalvular leak, or major vascular complications between the two groups (p>0.05). The unadjusted Kaplan-Meier survival estimate for TF-TAVR was significantly higher than for SC-TAVR (Figure 1, p=0.009, log-rank). However, on risk adjustment with multivariable Cox analysis, subclavian access was not significantly associated with an increased hazard of death as compared to transfemoral access (Table 1, p=0.21).Conclusions: Outcomes of SC-TAVR are comparable with those of TF-
TAVR. Subclavian access may be favorable when TF-TAVR is contraindicated.

Table 1. Cox proportional-hazards regression model for mortality in the entire cohort (n=1095)
VariableHazard Ratio95% CIp-value
Subclavian (ref: transfemoral)1.200.90, 1.580.21
Race (ref: white)
Black
Other
0.99
0.58
0.52, 1.86
0.33, 1.04
0.97
0.07
Chronic pulmonary disease1.481.22, 1.81<0.001
Peripheral vascular disease1.170.96, 1.440.12
Urgent/emergent status (ref: elective)1.291.04, 1.600.02
Preoperative creatinine (mg/dl)1.101.03, 1.18<0.001



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