Comparative Intermediate-Term Outcomes of Subclavian and Transcaval Access for Transcatheter Aortic Valve Replacement

BACKGROUND: Multiple alternative access routes have been employed for patients with contraindications to standard transfemoral transcatheter aortic valve replacement (TAVR); however, the optimal route for alternative access approaches is not established. In order to better understand possible differences in alternative access routes, we compared the procedural efficacy and outcomes at 30 days and 1 year in patients who underwent TAVR via subclavian (SC) or transcaval (TC) access route at a single, tertiary-care center. METHODS: This retrospective analysis included all TAVR procedures performed via SC or TC approaches between December 2011 to January 2020, with outcomes reported to 1 year post procedure. Additional safety and feasibility studies, including successful device deployment, procedural time, blood loss, and total hospitalization length, are included as part of this study. RESULTS: A total of 41 patients underwent SC access and 22 patients underwent TC access for TAVR. Between both cohorts, SC patients were older at the time of TAVR (83.2 ± 3.7 years for SC vs 80.7 ± 3.9 years for TC; P=.03) and all patients were previously deemed high or prohibitive surgical risk (Society of Thoracic Surgeons score, aortic valve replacement only: 10.4 ± 2.6% for SC vs 9.0 ± 1.9% for TC; P=.12), with similar preoperative hemodynamic profiles. PROCEDURAL SAFETY: Device deployment was successful in all patients in both groups, with longer procedural times noted in the SC cohort (62.1 ± 12.1 minutes for SC vs 39.8 ± 12.5 minutes for TC; P<.05). There were no in-hospital deaths in the SC group and 1 intraoperative death in the TC group that was unrelated to access route. Average length of hospital stay was consistent between the two groups (3.8 ± 1.4 days for SC vs 3.4 ± 1.1 days for TC; P=.06). More cerebrovascular accidents were noted in the SC group at 30 days (6 for SC vs 1 for TC), 6 months (3 for SC vs 0 for TC), and 1 year (2 for SC vs 0 for TC), with more postprocedural permanent pacemakers implanted in the SC group at 30 days (9 for SC vs 3 for TC; P<.05, but with fewer at 6 months (2 for SC vs 3 for TC) and 1 year (1 for SC vs 2 for TC). Mortality rate was not statistically different between the two groups at 30 days, 6 months, and 1 year (P>.05 for all). CONCLUSION: Both SC and TC access routes can be safe and feasible options for TAVR in patients at increased or prohibitive surgical risk with contraindications to standard transfemoral access.