Can Alternate Access be Just as Good? A High-Volume Center’s Experience with Carotid Transcatheter Aortic Valve Replacement

BACKGROUND Transcarotid access has been our preferred alternative access since 2018 for transcatheter aortic valve replacement (TAVR). Our objective was to compare outcomes between transfemoral and transcarotid access routes for TAVR at a high-volume center. METHODS All TAVRs at a single institution from January 2017-March 2024 were retrospectively reviewed. Our primary outcome was risk of stroke, vascular complication, or mortality at 30-days. Secondary outcomes included improvement in Kansas City Cardiomyopathy Questionnaire (KCCQ) scores and aortic valve mean gradients at 30 days. RESULTS Of 1,278 TAVR procedures, 104 (7.8%) were transcarotid. Patients undergoing a transcarotid approach were younger (75 years vs. 79 years, p=0.002) and more often received balloon expandable valves (55.8% vs. 36.5%, p<0.001). Median procedure time was slightly longer for transcarotid approach (75 [55-94] minutes vs. 66 [39-92] minutes, p=0.04). Both approaches resulted in a significant improvement in KCCQ scores (Transcarotid, 74.1 vs. 50.8) (Transfemoral, 74.4 vs. 52.3) (p<0.001) and mean gradients (Transcarotid, 9.4mmHg vs. 41.7mmHg) (Transfemoral, 9.8mmHg vs. 41.4mmHg) (p<0.001) at 30 days; valve type did not affect this rate of change. Multivariable analysis did not demonstrate transcarotid approach as associated with the composite outcome of death, stroke, or major vascular complication (OR=0.49 [0.15-1.62], p=0.24). CONCLUSIONS Transcarotid TAVR is associated with excellent outcomes, low stroke rate, and low operative mortality. Our series, along with accumulating registry data, make a case for transcarotid access as a safe and reproducible approach for centers who want to perform alternate access TAVR but concentrate expertise on one approach.