Right transaxillary transcatheter aortic valve replacement is comparable to left despite challenges

OBJECTIVES

Transaxillary access is the most popular alternative to transfemoral transcatheter aortic valve replacement. Although left transaxillary access is generally preferred, right transaxillary transcatheter aortic valve replacement could be challenging because of the opposing axillary artery and aortic curvatures, which may warrant procedural modifications to improve alignment. Our aim is to compare our single center's outcomes for left and right transaxillary access groups and to evaluate procedural modifications for facilitating right transaxillary transcatheter aortic valve replacement.

METHODS

Patient characteristics and outcomes were compared for consecutive left or right axillary TAVRs performed from 6/2016 to 6/2022 with SAPIEN 3. The effects of our previously reported "flip-n-flex" technique on procedural efficiency and new conduction disturbances were subanalyzed in the right axillary group.

RESULTS

Right and left transaxillary transcatheter aortic valve replacement were performed in 25 (18 with the "flip-n-flex" technique) and 26 patients, respectively. There were no significant differences between patient characteristics or outcomes. Right axillary subanalysis showed the "flip-n-flex" technique group had significantly shorter fluoroscopy times (21.2 ± 6.2 vs 29.6 ± 12.4 min, p = 0.03) and a trend towards less permanent pacemaker implantation (6.3% vs. 42.9%, p = 0.07) compared to the group without "flip-n-flex".

CONCLUSIONS

In our study, despite anatomical challenges, right transaxillary transcatheter aortic valve replacement is comparable to left access. The "flip-n-flex" technique advances right transaxillary as an appealing access for patients with few options.

Direct superficial temporal artery access for middle meningeal artery embolization

Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.

Alternative Access for Transcatheter Aortic Valve Replacement: A Comprehensive Review

Transfemoral is the most widely used access to perform transcatheter aortic valve replacement (TAVR). However, alternative access is needed in up to 21% of patients with TAVR because of a myriad of factors. The authors provide a comprehensive review on alternative access for TAVR, discussing the relevant data and providing the pros and cons of each access route.

Alternative Access for Mechanical Circulatory Support

Femoral arterial access is the default strategy for large-bore interventional procedures, including temporary mechanical circulatory support implantation and structural heart therapies, based on superior outcomes and operator ease. In addition to patient size and comorbidities, vessel tortuosity, significant calcification, and diminutive vessel caliber all may make iliofemoral access prohibitively high risk or impossible. Given the increase of large-bore transcatheter procedures, bleeding avoidance strategies are essential and thus novel mechanisms for large-bore access have evolved. This article highlights the advantages, limitations, and practical approaches to the 2 most common percutaneous large-bore alternative access strategies: transaxillary and transcaval access.

Simplified Trans-Axillary Aortic Valve Replacement Under Local Anesthesia - A Single-Center Early Experience

BACKGROUND

The axillary artery is an alternative route for patients with comorbidities and unfavorable femoral arteries who need transcatheter aortic valve replacement (TAVR). Simplified trans-axillary transcatheter aortic valve replacement (TAx-TAVR) implies a completely percutaneous approach under local anesthesia and arteriotomy closure with vascular closure techniques. Herein, we report on early experience with simplified TAx-TAVR under local anesthesia.

METHODS

We enrolled all consecutive patients who underwent simplified TAx-TAVR in our center. Main study parameter was the incidence of axillary access related major vascular complications within 30 days. Secondary parameters included a composite early safety endpoint, axillary access-site related vascular/bleeding complications and short-term mortality. Post TAVR axillary stent patency was evaluated during follow-up by CT-analysis.

RESULTS

Between July 2018 and April 2020, Tax-TAVR was attempted in 35 patients with a mean age of 79 years. Local anesthesia and conscious sedation were used in 91.4% (n = 32) and 8.6% (n = 3) respectively. A covered stent was needed for complete axillary hemostasis in 44.1% (n = 15). Device success was achieved in 91.2% (n = 31/34). The 30-day axillary artery major vascular and ≥major bleeding complication rates were 14% (n = 5) and 11% (n = 4). The early safety endpoint was reached in 22.9% (n = 8). Mortality rates at 30 days and six months were 2.9% and 11.6%. Computed tomography (CT) confirmed axillary stent patency during follow-up in 82% (n = 9/11).

CONCLUSIONS

In patients with high/prohibitive surgical risk and unsuitable femoral access, simplified TAx-TAVR under local anesthesia offers a valuable alternative for transfemoral TAVR but requires advanced access site management techniques including covered stents. Our data suggest an unmet clinical need for dedicated TAx closure devices.

Safety and efficacy of transaxillary transcatheter aortic valve replacement using a current-generation balloon-expandable valve

Background

Transaxillary access (TAx) has shown promise as an excellent alternative TAVR option, but data on the Edwards SAPIEN 3 in TAx-TAVR is limited. We sought to study the safety and efficacy of TAx-TAVR using this current-generation balloon-expandable valve.

Methods

A retrospective study of our first 24 TAx and 20 transthoracic (TT) TAVR patients treated with the SAPIEN 3 valve was performed, and the patients’ preoperative characteristics, procedural outcomes, and clinical outcomes were compared to our first 100 transfemoral (TF) patients using the SAPIEN 3 device.

Results

There were no statistical differences observed for outcomes between the TAx and TF groups, despite the TAx patients having more comorbidities (STS-PROM 11.3 ± 7.6 versus 7.3 ± 5.2, p = 0.042). In addition, no significant difference was found in the fluoroscopy time and contrast amount between the two groups. The patients’ baseline characteristics were similar between the TAx and TT groups. Their procedural and clinical outcomes were comparable, but there was a trend towards lower incidence of acute kidney injury (13.0% versus 23.5%), new-onset atrial fibrillation (5.6% versus 33.3%), shorter median length of stay postoperatively (4 versus 6 days), fewer discharges to rehabilitation (16.7% versus 35.0%), and a lower rate of readmission within 30-days (8.3% versus 35.0%), all favoring TAx access.

Conclusions

TAx-TAVR with the SAPIEN 3 valve is a safe alternative to TF access. It offers advantages of improved recovery over TT access, and appears to be a superior alternative-access option for TAVR. TAx access could be preferred when TF access is not feasible.

RadialFirst in CHIP and Cardiogenic Shock

This article highlights the advantages and disadvantages of transradial arterial (TRA) access for a variety of presentations including acute coronary syndromes; cardiogenic shock; unprotected left main, heavily calcified coronaries; bifurcations; and chronic total occlusions. It includes techniques for overcoming challenges of using TRA access, including spasm and the need for larger bore guides. In addition, the authors review the use of ultrasound for access, percutaneous hemodynamic support via axillary approach, and tips and tricks to performing right heart catheterizations from the antecubital vein.

Transcaval Access for Large Bore Devices

PURPOSE OF REVIEW

Examine the latest data and techniques regarding transcaval access and closure.

RECENT FINDINGS

Transcaval access was proven to be a feasible and a translatable skill in a 100 patient open-label prospective study. No late complications from fistulas occurred and of all patients alive at 1 year, one fistula remained open. Transcaval is a viable access route for large bore devices. With adequate planning, bleeding and vascular complications are minimal. It should be integrated into the rubric of transcatheter large bore access.

A case series: alternative access for refractory shock during cardiac arrest

BACKGROUND

In patients with iliofemoral arterial disease, transcaval and percutaneous axillary artery access are safe alternatives for delivery of transcatheter aortic valve replacement for severe aortic stenosis. In the setting of cardiac arrest, arterial access is crucial for delivery of mechanical circulatory support devices such as an Impella CP® or cannulation for extracorporeal cardiopulmonary resuscitation (ECMO). We report the use of transcaval and axillary artery access in three cases of cardiac arrest in which the emergent placement of an Impella CP® (Abiomed, Danvers, MA, USA) or cannulation for ECMO was instrumental in resuscitation from refractory cardiac arrest.

CASE SUMMARY

The first patient is a 59-year-old woman who developed ventricular fibrillation arrest after percutaneous intervention with emergent placement of a transcaval Impella CP®. In the second case, a 67-year-old man with coronary vasospasm developed cardiac arrest with an axillary artery Impella CP® placed. The third case highlights a 67-year-old man who developed cardiac arrest 1 day after unsuccessful chronic total occlusion repair requiring ECMO cannulation to his axillary artery. All three patients achieved spontaneous circulation after placement of assist devices.

DISCUSSION

To our knowledge, a case report of transcaval or percutaneous axillary artery access for Impella CP® during cardiac arrest has not been published. While the long-term prognosis following cardiac arrest is poor, younger patients deserve every chance for survival with rapid cardiopulmonary support by alternative access if necessary. Advanced large bore alternative access techniques should be learned by all interventional operators.

Transaortic Access Using Vascular Graft for Transcatheter Aortic Valve Implantation

A 92-year-old man with acute heart failure due to severe aortic stenosis underwent transcatheter aortic valve implantation (TAVI). Computed tomography demonstrated severe stenosis of the right common iliac artery, occlusion of the left external iliac artery, and stenosis of the left subclavian artery. Severe calcification was observed in the sinotubular junction, which was considered a risk factor for aortic dissection with transapical TAVI using a balloon-expanding bioprosthetic valve. Therefore, transaortic (TAo) access was the only option for this high-risk surgical patient. As the maximum distance from the aortic valve annulus to the sheath insertion point was less than 60 mm, TAVI was performed transaortically using a vascular graft that extended this distance, in order to avoid sheath dislocation. Our experience demonstrates that vascular graft application is a viable option in patients with an inadequate distance between the aortic valve annulus and the puncture site in TAo-TAVI.

"Liver or Let Die": Percutaneous PFO Closure Through Hepatic Vein Access

A 73-year-old farmer presented with platypnoea-orthodeoxia syndrome (POS). A transoesophageal echocardiogram (TOE) disclosed a patent foramen ovale (PFO) with significant right-to-left shunt on assuming upright posture. An initial attempt at PFO closure through the femoral vein was abandoned due to a completely occluded inferior vena cava. A second attempt through the internal jugular vein was also unsuccessful due to the steep angulation between superior vena cava and septum primum flap. Because of disabling symptoms, an attempt through a hepatic vein (HV) was scheduled and performed under general anaesthesia with TOE guidance. Ultrasound-guided access through an intercostal window to a peripheral HV was performed and the position confirmed with contrast injections. The PFO was easily crossed with a glide wire which was exchanged to a stiffer guide wire. A 25mm closure device was successfully deployed across the PFO. After retrieval of the delivery system, haemostasis of the HV was attained with a contrast-guided Gelfoam (Pfizer, New York, NY, USA) injection. Unfortunately, the patient had to undergo subsequent emergency coiling to an iatrogenically injured hepatic artery branch leading to full recovery and significant clinical improvement. Subsequent echocardiography demonstrated a well-positioned device with no residual shunt. This case illustrates that percutaneous PFO closure through a HV is a feasible procedure and should be considered in anatomy that is otherwise prohibitive for conventional approach. Extra care should be taken with initial vascular access into the HV and final haemostasis of the access site.

A Review of Alternative Access for Transcatheter Aortic Valve Replacement

With the advent of transcatheter aortic valve replacement (TAVR), appropriately selected intermediate-, high-, and extreme-risk patients with severe aortic stenosis (AS) are now offered a less invasive option compared to conventional surgery. In contemporary practice, TAVR is performed predominantly via a transfemoral arterial approach, whereby a transcatheter heart valve (THV) is delivered in a retrograde fashion through the iliofemoral arterial system and thoraco-abdominal aorta, into the native aortic valve annulus. While the majority of patients possess suitable anatomy for transfemoral arterial access, there is a subset of patients with extensive peripheral vascular disease that precludes this traditional approach to TAVR. Fortunately, innovation in the field of structural heart disease has led to the refinement of alternative access options for THV delivery. Selection of the most appropriate route of therapy mandates a careful consideration of multiple factors, including patient anatomy, technical feasibility, and equipment specifications. Furthermore, understanding the risks conferred by each access site for valve delivery-notably stroke, vascular injury, and major bleeding-is of paramount importance when selecting the approach that will best optimize the outcome for an individual. In this review, we provide a comprehensive summary of alternative approaches to transfemoral arterial TAVR as well as the available outcome data supporting each of these various techniques.

Alternate Access for TAVI: Stay Clear of the Chest

Transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. The transapical access is progressively being abandoned as a result of its invasiveness and poor outcomes. Existing data does not allow TAVI operators to favour one access over another - between transcarotid, trans-subclavian and transaortic - because all have specific strengths and weaknesses. The percutaneous trans-subclavian access might become the main surgery-free alternative access, although further research is needed regarding its safety. Moreover, the difficult learning curve might compromise its adoption. The transcaval access is at an experimental stage and requires the development of dedicated cavo-aortic crossing techniques and closure devices.