Comparative Outcomes of Alternative Access Site Versus Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Replacement: A Single-Center Retrospective Study

A Meta-Analysis of Mortality and Major Adverse Cardiovascular and Cerebrovascular Events in Patients Undergoing Transfemoral Versus Transapical Transcatheter Aortic Valve Implantation Using Edwards Valve for Severe Aortic Stenosis

The Axillary/Subclavian Artery Access Route for Transcatheter Aortic Valve Replacement: A Systematic Review of the Literature

Transcatheter aortic valve implantation (TAVI) is currently an established therapy for elderly patients with symptomatic severe aortic valve stenosis across all surgical risk categories. Access is an important aspect when planning for and performing TAVI. The superiority of a transfemoral (TF) approach compared to a transthoracic (transapical, direct aortic) approach has been demonstrated in several studies. Recently, the introduction of intravascular lithotripsy (IVL) has made it possible to treat patients with calcified iliofemoral disease by TF approach. This article aimed to provide a comprehensive overview on the following aspects: (1) preprocedural planning for IVL-assisted TF-TAVI; (2) procedural aspects in IVL-assisted TF-TAVI; (3) outcomes of IVL-assisted TF-TAVI in an experienced TAVI center; and (4) literature review and discussion of this new emerging approach.

Transcatheter aortic valve replacement (TAVR) has become a well-established treatment for severe aortic stenosis across all levels of surgical risk. While transfemoral access remains the default approach, complications arising from vascular access-especially in patients with peripheral artery disease (PAD)-pose significant challenges. Hostile vascular access, characterized by narrow vessel diameters, severe calcification, and tortuosity, complicates the procedure and necessitates alternative strategies. Recent advancements, such as intravascular lithotripsy (IVL), have shown promise in managing severely calcified arteries, improving the feasibility of transfemoral TAVR in patients previously considered ineligible. IVL uses pulsatile sonic waves to fragment arterial calcifications, enhancing vessel compliance and facilitating safe device delivery. Studies have demonstrated that IVL-assisted TAVR improves procedural success and reduces complications in patients with PAD. Additionally, orbital atherectomy, an adjunctive therapy targeting both concentric and eccentric calcifications, may complement the management of complex arterial calcification. The Hostile and passage-puncture scores offer valuable risk stratification tools for predicting vascular complications, aiding in better access site selection. Post-procedural echocardiography, particularly femoral artery sonography, may also play a role in detecting vascular complications early, enabling timely intervention. Finally, alternative access sites are increasingly being explored, with emerging data helping to guide the final access site decision. As TAVR continues to expand into lower risk populations, optimizing vascular access strategies remains essential to improving procedural outcomes. This review highlights the importance of preoperative imaging, endovascular techniques, and post-procedural monitoring in overcoming vascular challenges and ensuring successful TAVR outcomes.

Network Meta-Analysis Comparing the Short- and Long-Term Outcomes of Alternative Access for Transcatheter Aortic Valve Replacement

The role of the vascular surgeon in transcatheter aortic valve implantation.

Intravascular Lithotripsy Enabled Transfemoral Transcatheter Aortic Valve Implantation via Percutaneous Axillary Access Approach

Alternative Access for TAVR: A State-of-the-Art Review and Practical Guide.

Introduction Stent underexpansion significantly heightens the risk of major adverse cardiac events (MACE), and available treatment options for this condition remain limited. Intravascular Lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, emerges as a promising tool for underexpanded stents. Methods Following PRISMA guidelines, we systematically explored PubMed, SCOPUS, and Cochrane databases up to September 3, 2023, for studies evaluating IVL's safety and efficacy in treating underexpanded stents. We gathered angiographic (QCA) and intracoronary imaging (OCT or IVUS) data, examining the stent's minimal diameter stenosis (MDS), minimal lumen diameter (MLD), minimal stent area (MSA), and minimal lumen area (MLA) pre- and post-IVL application. Procedural success constituted the efficacy endpoint, while peri-procedural complications, in-hospital-30-days and long-term mortality, and MACE were safety endpoints Results This meta-analysis comprised 21 studies including 669 patients and 673 treated lesions in underexpanded stent. The mean age was 73.2 ± 2.1 years, with an overall IVL procedural success rate of 93% [(95% Confidence Interval (CI): 88%-96%, I2=29%), while the in-hospital-30-days and long-term mortality incidence were 1% (95% CI: 1%-3%, I2=0%) and 3% (95% CI: 2%-6%, I2=0), respectively. The 30-days target lesion revascularization (TLR) was approximately 6% (95% CI: 3%-12%, I2=50%). There was a significant increase in the MDS [Standardized Mean Difference (SMD): +50.52%, 95% CI: 39.4-61.6, I2=94%)] and in MSA (SMD: +3.52, 95% CI: 2.47 to -4.58, I2=83%) immediately after IVL application. It was observed a significant increase in MLD (SMD: +1.54, 95% CI: 1.09 to 1.98, I2=95%) and in the MLA (SMD: +3.64, 95% CI: 2.62-4.66, I2=5%). Major procedural and device related complications were 3% (95% CI: 1%-6%, I2=0%) and 1% (95% CI: 0%-2%, I2=85%) respectively. Notably low rates were observed for stent thrombosis (0%, 95% CI: 0%-2%, I2=0%), dissections (1%, 95% CI: 1%-4%, I2=0%), perforations (1%, 95% CI: 1%-3%, I2=0%) and no-reflow (0%, 95% CI: 0%-1%, I2=0%). Conclusions IVL demonstrates promise as a safe and effective strategy for underexpanded stent treatment, characterized by low rates of periprocedural complications. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.30day All-Cause Mortality after IVL use.Minimum Stent Diameter after IVL use.

Stent underexpansion significantly heightens the risk of major adverse cardiac events (MACE), and available treatment options for this condition remain limited. Intravascular Lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, emerges as a promising tool for underexpanded stents. This study examines the overall efficacy and safety of IVL, an until-now off-label modality, in the management of underexpanded stents. Following PRISMA guidelines, we systematically explored PubMed, SCOPUS, and Cochrane databases up to April 30, 2024, for studies evaluating IVL's safety and efficacy in treating underexpanded stents. We gathered angiographic (QCA) and intracoronary imaging (OCT or IVUS) data, examining the stent's diameter stenosis (SDS), minimal lumen diameter (MLD), minimal stent area (MSA), and minimal lumen area (MLA) pre- and post-IVL application. Procedural success constituted the efficacy endpoint, while peri-procedural complications, in-hospital-30-days and long-term mortality, and MACE were safety endpoints. This meta-analysis comprised 23 studies including 819 patients and 837 treated lesions in underexpanded stent. The mean age was 71.7 ± 8.8 years, with an overall IVL procedural success rate of 92% [(95% confidence interval (CI): 88%-95%, I2 = 35%), while the in-hospital-30-days and long-term mortality incidence were 1% (95% CI: 1%-3%, I2 = 0%) and 4% (95% CI: 2%-6%, I2 = 0), respectively. The 30-day rates acute myocardial infarction and stroke were 1% [(95% CI: 0%-1%, I² = 0%), (95% CI: 0%-2%, I2 = 0%)] each. No need for short term target lesion revascularization (TLR) was observed while the long-term rates were 6% (95% CI: 3%-10%, I2 = 48%). There was a significant decrease in the SDS [Standardized Mean Difference (SMD): -3.57 (95% CI: -4.64 to -2.44%, I2 = 94%)] and increase in MSA (SMD: +1.98, 95% CI: 0.86-3.09, I2 = 93%) after IVL application. It was observed a significant increase in MLD (SMD: +2.68, 95% CI: 1.94-3.41, I2 = 90%) and in the MLA (SMD: +1.92, 95% CI: 1.46-2.38, I2 = 69%). Major procedural and device related complications were 2% (95% CI: 1%-5%, I2 = 0%) and 1% (95% CI: 0%-2%, I2 = 80%) respectively. Notably low rates were observed for stent thrombosis (1%, 95% CI: 0%-2%, I2 = 0%), dissections (1%, 95% CI: 1%-4%, I2 = 0%), perforations (1%, 95% CI: 1%-3%, I2 = 0%) and no-reflow (0%, 95% CI: 0%-46%, I2 = 0%). IVL demonstrates promise as a safe and effective strategy for underexpanded stent treatment, characterized by low rates of periprocedural complications. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.

Left distal radial artery (LDRA) has got high popularity as an alternative safe access site in coronary angiography. However, little is known about its applicability in primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) patients. We aimed to assess the convenience of LDRA access in STEMI patients and make the comparative evaluation with the transfemoral (TF) route. A total of 91 consecutive STEMI patients who underwent PPCI from January to June 2019, were analyzed. Experienced operators, unaware of the study were left free of access site decision. Comparative demographic features and clinical outcomes were recorded during hospitalization. LDRA was used in 30 patients, whereas 61 patients underwent a TF approach. Successful PPCI was achieved in high rates in both groups (LDR: 90% vs TF: 91.8%: p = 0.795). On admission, KILLIP (II, III) class was higher in the LDRA group (23.3% vs 3.4%), whereas stent thrombosis, arhythmias were higher in the TF group (0% vs 6.6% p = 0.151; 6.7% vs 18% p = 0.355 respectively). Puncture time was relatively similar between groups (28.63 vs 28.93 s p = 0.767). Fluoroscopy time, total radiation exposure and hospital duration was found lower in the LDRA group (10.11 vs 13.75 min p < 0.001; 917.87 vs 1940.91 mGy p < 0.001; 4.2 vs 6.2 days p = 0.024 respectively). In-hospital mortality was found higher in the TF group (0% vs 18% p = 0.013). In the acute management of STEMI, LDRA access site can be a convenient alternative to TF approach with shorter hospital duration and complication rates.

Self-expanding transcatheter aortic valve replacement using alternative access sites in symptomatic patients with severe aortic stenosis deemed extreme risk of surgery

When transfemoral (TF) access is contraindicated in patients undergoing transcatheter aortic valve replacement (TAVR), alternate access strategies are considered. The choice of one alternate access over the other remains controversial. Following a comprehensive literature search, studies comparing any combination of TF, transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) TAVR were identified. Data were pooled using fixed- and random-effects network meta-analysis. Rank scores with probability ranks of different treatment groups were calculated. Eighty-four studies (26,449 patients) were included. Compared to TF access, TA and TAo accesses were associated with higher 30-day mortality (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.31-1.94; OR 1.79, 95% CI 1.21-2.66, respectively), while the TC and TS showed no difference (OR 1.12, 95% CI 0.64-1.95; OR 1.23, 95% CI 0.67-2.27, respectively); TF access ranked best followed by TC. There was no significant difference in 30-day stroke; TC access ranked best followed by TS. At a weighted mean follow-up of 1.6 years, TA and TAo accesses were associated with higher long-term mortality versus TF (incidence rate ratio [IRR] 1.31, 95% CI 1.18-1.45; IRR 1.41, 95% CI 1.11-1.79, respectively); there was no difference between TC and TS versus TF access (IRR 1.02, 95% CI 0.70-1.47; IRR 1.16, 95% CI 0.82-1.66, respectively); TF access ranked best followed by TC. At a weighted mean follow-up of 1.4 years, only TA access was associated with higher long-term stroke compared to TF (IRR 3.01, 95% CI 1.15-7.87); TF access ranked as the best strategy followed by TAo. TC and TS approaches are associated with superior postoperative outcomes compared to other TAVR alternate access strategies. Randomized trials definitively assessing the safety and efficacy of alternate access strategies are needed.

Pre-procedural valvuloarterial impedance (Zva) is considered as a useful predictor of mortality in patients diagnosed as having severe aortic stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the prognostic significance of post-procedural Zva remains unclear. We aimed to evaluate the prognostic significance of Zva after TAVI. We retrospectively analyzed the clinical and echocardiographic data of 1004 consecutive elderly patients (median 84years old, 27.5% men) who underwent TAVI for severe symptomatic AS. Zva was calculated after TAVI, and patients were divided into three groups based on tertile values: the high [>3.33 (n=335)], intermediate [2.49-3.33 (n=334)], and low Zva groups [<2.49 (n=335)]. The estimated 2-year all-cause and cardiovascular mortalities using Kaplan-Meier analysis were 16.2% [95% confidence interval (CI) 11.8-20.4] and 5.9% (95% CI 3.2-8.6), respectively. There were no significant intergroup differences in each endpoint (long-rank p=0.518 for all-cause mortality, p=0.757 for cardiovascular mortality). Multivariable Cox regression analyzes with adjustments of patient characteristics and medications showed that the post-procedural Zva was not associated with the 2-year all-cause mortality [intermediate Zva group versus (vs.) low Zva group: adjusted hazard ratio (aHR)=1.34, 95% CI 0.75-2.40, p=0.316; high Zva group vs. low Zva group: aHR=1.17, 95% CI 0.64-2.16, p=0.613] and cardiovascular mortality (intermediate Zva group vs. low Zva group: aHR=1.50, 95% CI 0.56-4.06, p=0.421; high Zva group vs. low Zva group: aHR=1.25, 95% CI 0.43-3.65, p=0.682). Our results suggest that post-procedural Zva was not associated with 2-year all-cause or cardiovascular mortalities in patients with severe symptomatic AS who underwent TAVI.

Endograft Repair of Aortic Anastomotic Aneurysms