Key result
Intrathoracic access for TAVR was associated with a higher risk of in-hospital or 30-day all-cause mortality compared with extrathoracic access (RR 1.99; 95% CI 1.67-2.36; p<0.001).
Why the study?
Alternative vascular accesses to transfemoral TAVR include intrathoracic and extrathoracic approaches, but their comparative outcomes and safety required evaluation.
Does extrathoracic access improve outcomes and reduce complications compared to intrathoracic access in patients undergoing TAVR?
Systematic Review (n=11,832)
Does extrathoracic access improve outcomes and reduce complications compared to intrathoracic access in patients undergoing TAVR?
Extrathoracic access for TAVR is associated with lower short- and long-term mortality and fewer critical complications compared to intrathoracic access, suggesting it should be the preferred alternative when transfemoral access is contraindicated.
Extrathoracic access may be preferred when transfemoral is infeasible; extends meta-analytic evidence on access-related mortality.
Alternative vascular accesses to transfemoral access for transcatheter aortic valve replacement (TAVR) can be divided into intrathoracic (IT)-transapical and transaortic- and extrathoracic (ET)-transcarotid, transsubclavian, and transaxillary. This study aimed to compare the outcomes and safety of IT and ET accesses for TAVR as alternatives to transfemoral access. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all studies comparing IT-TAVR with ET-TAVR published until April 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM), 1-year ACM, postoperative and 30-day complications. A total of 18 studies with 6,800 IT-TAVR patients and 5,032 ET-TAVR patients were included. IT accesses were associated with a significantly higher risk of in-hospital or 30-day ACM (relative risk 1.99, 95% confidence interval 1.67 to 2.36, p <0.001), and 1-year ACM (relative risk 1.31, 95% confidence interval 1.21 to 1.42, p <0.001). IT-TAVR patients presented more often with postoperative life-threatening bleeding, 30-day new-onset atrial fibrillation or flutter, and 30-day acute kidney injury needing renal replacement therapy. The risks of postoperative permanent pacemaker implantation and significant paravalvular leak were lower with IT-TAVR. ET-TAVR patients were more likely to be directly discharged home. There was no statistically significant difference regarding the 30-day risk of stroke. Compared with ET-TAVR, IT-TAVR was associated with higher risks of in-hospital or 30-day ACM, 1-year ACM and higher risks for some critical postprocedural and 30-day complications. Our results suggest that ET-TAVR could be considered as the first-choice alternative approach when transfemoral access is contraindicated.
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Abellan et al. (2023) conducted a systematic review in Transcatheter aortic valve replacement (TAVR) (n=11,832). Intrathoracic (IT) vascular access vs. Extrathoracic (ET) vascular access was evaluated on In-hospital or 30-day all-cause mortality (RR 1.99, 95% CI 1.67 to 2.36, p=<0.001). Intrathoracic access for TAVR was associated with a higher risk of in-hospital or 30-day all-cause mortality compared with extrathoracic access (RR 1.99; 95% CI 1.67-2.36; p<0.001).
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