Comparison of transcarotid vs. complex transfemoral access in patients undergoing transcatheter aortic-valve implantation (TAVI)

Abstract

Transfemoral (TF) access is considered as the default approach in patients undergoing TAVI. However, ilio-femoral anatomic considerations as diameter, tortuosities and calcifications have to be taken into account and alternatives routes as transcarotid (TC) may be considered. This study compare outcomes between “complex” TF (cTF) and TC in patients undergoing TAVI. All consecutive patients undergoing TAVI via cTF and TC in our center between 2015 and 2018 were included in this retrospective study. A cTF approach was defined as a common femoral artery < 6.5 mm of diameter with at least severe calcifications or severe tortuosity assessed by CT scan. TF or TC approach was performed according to the heart team decision. The primary endpoint was 1-month outcomes including mortality, major vascular complications, bleeding and stroke. The study included 131 patients with 51 of them who underwent cTF TAVI (39,2%) whereas 80 patients underwent TC TAVI (60,8%). The mean age was 81.7 ± 6.9 years. Patients in the TC group had a higher operative risk profile (STS score 5.5 vs 7.7; P = 0.01), a lower left ventricular fraction (44% vs 53%; P ≤ 0.001) and a higher incidence of coronary artery disease (61% vs 38%, P = 0.04) compared with cTF patients. Prevalence of female was higher in the cTF group compared to the TC group (66% vs 31% P ≤ 0.0001). There were no significant differences in term of 30 day mortality (1.9% vs. 2.5%; P = 1) or stroke rate (1.9% vs. 2.5%; P = 1) or bleeding rate (11.7% vs. 7.5%; P = 0.53) between the cTF group and the TC group but major vascular complications occurred with a higher frequency in the cTF group (cTF:11.7%; TC:2.5%; P = 0.05) Despite a higher risk profile patients, the TC approach provided similar results in term of mortality, stroke, bleeding but was associated with a lower risk of major vascular complications. Carotid access could be considered in challenging femoral anatomy for TAVI procedures.