Key result
Transcarotid access for TAVR was associated with a significantly lower rate of 30-day stroke compared with transaxillary access (3.1% vs 5.9%; P=0.017).
Why the study?
Use of transcarotid TAVR is increasing, but comparative data versus transaxillary access for TAVR with a self-expanding valve are limited.
Does transcarotid access improve clinical outcomes compared to transaxillary access in patients undergoing TAVR with a self-expanding valve?
Cohort (n=1,718)
Yes
Does transcarotid access improve clinical outcomes compared to transaxillary access in patients undergoing TAVR with a self-expanding valve?
Hazard Ratio: 2.14 (95% CI 1.27–3.58)
Absolute Event Rate: 3.1% vs 5.9%
p-value: p=0.017
Transcarotid access for TAVR with a self-expanding valve is associated with shorter procedure times, shorter hospital stays, and lower 30-day stroke rates compared to transaxillary access.
Transcarotid access may lower stroke risk versus transaxillary in nonfemoral self-expanding TAVR; leaves open need for randomized confirmation before practice change.
Transaxillary access has been the most frequently used nonfemoral access route for transcatheter aortic valve replacement (TAVR) with a self-expanding valve. Use of transcarotid TAVR is increasing; however, comparative data on these methods are limited. We compared outcomes following transcarotid or transaxillary TAVR with a self-expanding, supra-annular valve. Methods The Transcatheter Valve Therapy Registry was queried for TAVR procedures using transaxillary and transcarotid access between July 2015 and June 2021. Patients received a self-expanding Evolut R, PRO, or PRO + valve (Medtronic) and had 1-year follow-up. Thirty-day and 1-year outcomes were compared in transcarotid and transaxillary groups after 1:2 propensity score-matching. Multivariable regression models were fitted to identify predictors of key end points. Results The propensity score–matched cohort included 576 patients receiving transcarotid and 1142 receiving transaxillary access. Median procedure time (99 vs 118 minutes; P < .001) and hospital stay (2 vs 3 days; P < .001) were shorter with transcarotid versus transaxillary access. At 30 days, patients with transcarotid access had similar mortality (Kaplan–Meier estimates 3.7% vs 4.3%, P = .57) but significantly lower stroke (3.1% vs 5.9%; P = .017) and mortality or stroke (6.0% vs 8.9%; P = .033) compared with patients receiving transaxillary access. Similar differences were observed at 1 year. Transaxillary access was associated with increased risk of 30-day stroke (hazard ratio, 2.14; 95% confidence interval, 1.27-3.58) by multivariable regression analysis. Conclusions Transcarotid versus transaxillary access for TAVR using a self-expanding valve is associated with procedural benefits and significantly lower stroke and mortality or stroke at 30 days. In patients with unsuitable femoral anatomy, transcarotid access may be the preferred delivery route for self-expanding valves.
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Allen et al. (2023) conducted a cohort in Transcatheter aortic valve replacement (TAVR) (n=1,718). Transcarotid access vs. Transaxillary access was evaluated on 30-day stroke (HR 2.14, 95% CI 1.27-3.58, p=0.017). Transcarotid access for TAVR was associated with a significantly lower rate of 30-day stroke compared with transaxillary access (3.1% vs 5.9%; P=0.017).
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