Key result
Transaxillary TAVI shows similar success to transaortic but links to ~3.7-fold higher pacemaker risk.
Why the study?
About one-third of TAVI candidates have severe peripheral artery disease making femoral access difficult, necessitating comparison of alternative access routes.
Does the transaortic approach improve procedural and clinical outcomes compared to the transaxillary approach in patients undergoing TAVI?
Cohort (n=242)
Yes
Does the transaortic approach improve procedural and clinical outcomes compared to the transaxillary approach in patients undergoing TAVI?
p-value: p=0.16
The transaortic approach for TAVI offers similar device success and lower pacemaker rates compared to the transaxillary route, but is associated with a higher risk of acute kidney injury and longer hospital stays.
Both TAx and TAo routes show comparable device success and 1-year outcomes in nonfemoral TAVI; leaves open preferred access pending randomized data.
BACKGROUND: About one-third of candidates for transcatheter aortic valve implantation (TAVI) suffer from severe peripheral artery disease, making the routine femoral approach difficult or impossible. The aim was to compare the transaxillary (TAx) and the transaortic (TAo) route for TAVI with Medtronic CoreValve Revalving System (CRS). METHODS: Out of 1049 consecutive TAVI with 18F CRS, 242 (23%) were treated in 4 high-volume Italian Centre through TAx (61%) and TAo (39%). RESULTS: The devices success was similar (P=0.16) with a trend to a lower incidence of significant paravalvular leak (6% vs. 14%, P=0.07) and a significant reduction of permanent pacemaker (PPM) implantation (13% vs. 34%, P=0.017) in the TAo. However, this route showed a higher incidence of acute kidney injury (P=0.016) and a longer hospital stay after the index procedure (days 10 [8-14] vs. 8 [7-12], P=0.001). By a multivariate analysis the vascular access is an independent predictor for a longer hospital stay (TAo route; OR=0.37, 95% CI: 0.18-0.75; P=0.006) and for PPM implantation (TAx route; OR=3.7, 95% CI: 1.2-10.8; P=0.017). CONCLUSIONS: Although the higher clinical risk profile of transaortic population, the TAo approach showed an equally high device success with similar 30-day safety and 1year efficacy, compared to TAx route. However, due to non-procedure-specific complications post-TAo TAVI, this route requires a specialized postoperative care and the treatment of patients in highly specialized and experienced centers.
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Fiorina et al. (2017) conducted a cohort in Severe peripheral artery disease requiring TAVI (n=242). Transaxillary (TAx) approach vs. Transaortic (TAo) approach was evaluated on Device success (p=0.16). The transaxillary approach for TAVI showed similar device success to the transaortic route (P=0.16) but was an independent predictor for permanent pacemaker implantation (OR 3.7; 95% CI 1.2-10.8).
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