855 Methods of Vascular Access for Transcatheter Aortic Valve Implantation (TAVI) at an Australian Centre

Abstract

While the majority of TAVI is performed trans-femorally, this method of access is not attainable in all cases. Initially transthoracic, typically transapical, approaches were utilised with cardiothoracic support for these cases, however these techniques have subsequently been demonstrated to produce inferior patient outcomes [[1]Makkar R.R. Thourani V.H. Mack M.J. Kodali S.K. Kapadia S. Webb J.G. et al.Five-Year Outcomes of Transcatheter or Surgical Aortic-Valve Replacement.New England Journal of Medicine. 2020; 382: 799-809Crossref PubMed Scopus (329) Google Scholar]. All patients who underwent TAVI at a single centre from 2008 to 2019 were reviewed in a retrospective registry analysis. Demographics, point of vascular access and procedural outcomes were collected. A total 522 TAVIs were performed. There were 498 trans-femoral, 16 transapical, 2 direct aortic, 2 subclavian, 1 carotid and 3 trans-caval cases, one of which was abandoned due to inability to access the aorta and then completed trans-femorally with vascular surgical support. Of the 16 trans-apical cases, 8 were in 2009, and the last trans-apical case was performed at our centre in 2017, after which this approach has been abandoned due to increasing evidence, although not at our centre, of poorer operative outcomes in this cohort. All other cases where methods of alternate vascular access were used proceeded without vascular injury, stroke or major bleeding complications. While transfemoral access is the established point of vascular access for TAVI, in some cases, mainly owing to individual vascular anatomy, alternate methods must be pursued. While the transapical approach has fallen out of favour, several other routes, including trans-caval, direct aortic, subclavian and carotid have proceeded without significant complication at our centre.