Key result
Transcarotid access for transcatheter aortic valve replacement was associated with a significantly higher 30-day mortality risk (RR 1.41) compared to transfemoral access, likely related to a higher baseline surgical risk and comorbidity burden.
Why the study?
Although transfemoral access is the gold standard for TAVR, alternative accesses such as transcarotid are needed in 10-15% of patients, warranting a comparison of 30-day mortality and complications.
Meta-Analysis (n=5,080)
Relative Risk: 1.41 (95% CI 1.02–1.96)
p-value: p=0.040
Supports caution with transcarotid TAVR access; leaves open whether excess mortality is access-specific after comorbidity adjustment.
Background: The transfemoral (TF) route is the gold-standard access for transcatheter aortic valve replacement (TAVR). In 10–15% of patients, alternative accesses are needed, such as the transcarotid (TC) access. We performed a meta-analysis to compare 30-day mortality and complications between TC-TAVR and TF-TAVR. Methods: We searched PubMed/MEDLINE and EMBASE from inception to January 2021 to identify articles comparing TC-TAVR and TF-TAVR. Patients' baseline characteristics, procedural outcomes, and clinical 30-day outcomes were extracted. Results: We identified 9 studies, among which 2 used propensity-score matching, including 1,374 TC patients and 3,706 TF patients. TC-TAVR was associated with significantly higher EuroSCORE II and Logistic EuroSCORE values (respectively 8.0 ± 6.7 vs. 6.3 ± 5.4, p = 0.002 and 20.8 ± 14.2% vs. 20.0 ± 13.4%, p = 0.04), a higher prevalence of peripheral artery disease (52.6 vs. 32.8%, p = 0.001), previous cardiac surgery (26.3 vs. 22.4%, p = 0.008) and coronary artery disease (64.6 vs. 60.5%, p = 0.020). The pooled results found TC-TAVR to be associated with a significantly higher 30-day mortality risk (RR, 1.41, 95% CI, 1.02–1.96, p = 0.040), and a lower rate of 30-day major vascular complications (RR, 0.48, 95% CI, 0.25–0.92, p = 0.030). No significant difference was found regarding permanent pacemaker implantation, major bleeding and acute kidney injury. A subgroup analysis of the two propensity-score matched studies found a statistically increased risk of 30-day neurovascular complications (RR, 1.61, 95% CI, 1.02–2.55, p = 0.040). Conclusion: Compared with TF-TAVR, TC-TAVR was associated with an increased risk of 30-day mortality, likely related to a higher surgical risk and comorbidity burden, and with an increased risk of 30-day neurovascular complications. Careful preprocedural patient selection and close periprocedural neurological monitoring are paramount.
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Lu et al. (2021) conducted a meta-analysis in Aortic valve stenosis requiring TAVR (n=5,080). Transcarotid access for TAVR vs. Transfemoral access for TAVR was evaluated on 30-day all-cause mortality (RR 1.41, 95% CI 1.02-1.96, p=0.040). Transcarotid access for transcatheter aortic valve replacement was associated with a significantly higher 30-day mortality risk (RR 1.41) compared to transfemoral access, likely related to a higher baseline surgical risk and comorbidity burden.
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