Transinnominate approach for transcatheter aortic valve replacement: single-centre experience of minimally invasive alternative access.

Abstract

Iliofemoral arteries have been the preferred access for transcatheter aortic valve replacement (TAVR). When these arteries are too small, calcified or tortuous, an alternative access must be considered. Transinnominate (TI) access is an extrathoracic approach that does not require manipulation of major neurovascular structures or the apex. The aim of this study is to evaluate the efficacy and safety of TI TAVR as an alternative access in patients with severe aortic stenosis not amenable to a transfemoral approach. Thirteen patients with severe aortic stenosis underwent TI TAVR between February 2016 and January 2017 at our institution. The average Society of Thoracic Surgeons (STS) score was 7.7 ± 4.5%. Eight patients had previous surgical revascularization, 7 of which involved the left thoracic artery. All patients underwent preoperative computed tomography angiography that revealed significant atheromatous and calcific disease of the iliofemoral vessels and/or the descending aorta. The innominate artery was found to be of appropriate calibre (>10 mm), free of plaque and easy to access via surgical incision. Fusion multimodality imaging was utilized in all cases to guide the procedure. The innominate artery was accessed via a 2-inch right parasternal supraclavicular incision. Nine self-expandable valves and 4 balloon-expandable valves were implanted. Procedural success occurred in all cases without intraprocedural and in-hospital mortality. No neurological deficits or vascular complications were recorded; postoperative bleeding was trivial. Ten patients were discharged on Day 3 and 3 patients who required PPM on Day 5. TI approach represents a safe, reproducible and minimally invasive hybrid technique for TAVR in high-risk patients. In our early experience, surgical trauma and perioperative complications are minimal with rapid patient recovery.