Percutaneous axillary vs femoral access for transcatheter aortic valve replacement: Insights from a 2164-patient study

BACKGROUND: Transaxillary (TAx) access is increasingly adopted for transcatheter aortic valve implantation (TAVR) in patients with challenging iliofemoral anatomy. We aimed at evaluating the early clinical outcomes of TAx vs transfemoral (TF) access for TAVR. METHODS: We conducted a retrospective observational study stemming from the prospective RISPEVA registry, including all consecutive patients undergoing TAVR since 2013 at our Institution, where TAx is the only alternative access site whenever TF is contraindicated. RESULTS: A total of 2164 patients were included: 60 (2.8 %) in the TAx group, and 2104 (97.2 %) in the TF group. Notably, no patient required alternative accesses or was referred for surgical aortic valve replacement. Baseline characteristics, including surgical risk scores such as EuroScore II (TAx = 5.3 ± 5.7, TF = 3.6 ± 3.7, p < 0.001) and comorbidities such as prior myocardial infarction (TAx = 10 [17.2 %], TF = 157 [8.1 %], p = 0.025), were clearly disfavoring the TAx group. Despite higher procedural times in the TAx group (69 ± 24 vs 59 ± 13 min, p < 0.001), procedural success rates were high in both groups (TAx = 58 [96.7 %], TF = 2077 [98.7 %], p = 0.191). Similarly, at 1-month follow-up there were no significant differences in all-cause mortality (TAx = 1 [1.7 %], TF = 26 [1.2 %], p = 0.534), stroke (TAx = 1 [1.7 %], TF = 11 [0.5 %], p = 0.287), myocardial infarction (TAx = 1 [1.7 %], TF = 8 [0.4 %], p = 0.224), major vascular complication (TAx = 4 [6.7 %], TF = 90 [4.3 %], p = 0.329), or major bleeding (TAx = 1 [1.7 %], TF = 36 [1.7 %], p = 1), as well as their composite (TAx = 7 [11.7 %], TF = 155 [7.4 %], risk difference = 4.3 % [95 % confidence interval - 3.9 % to 12.5 %], p = 0.210). Similar findings were obtained at multivariable adjusted analyses and those based on inverse probability of treatment weighting, despite their limited reliability given low event-per-variable ratios and instability. CONCLUSIONS: In this single-center retrospective study, TAx TAVR was feasible whenever TF was not envisionable, and yielded quite favorable short-term clinical outcomes. While promising, these findings remain descriptive and hypothesis-generating, thus requiring additional prospective and randomized validation.