Transcaval Transcatheter Aortic Valve Replacement for Pure Aortic Regurgitation Using a Dedicated Self-Expanding Device

Novel dedicated devices allow transcatheter treatment of pure aortic regurgitation (AR). The JenaValve Trilogy Heart Valve System was introduced as the first dedicated and on-label AR transcatheter aortic valve replacement system, implementing a locator-based and calcium-independent anchoring mechanism. Here, we present the first-in-human transcatheter aortic valve replacement for pure AR via a transcaval access in a patient with prohibitive alternative arterial accesses.

Transcaval versus Supra-Aortic Vascular Accesses for Transcatheter Aortic Valve Replacement: A Systematic Review with Meta-Analysis

A growing body of evidence suggests that extrathoracic vascular accesses for transcatheter aortic valve replacement (TAVR) yield favorable outcomes and can be considered as primary alternatives when the gold-standard transfemoral access is contraindicated. Data comparing the transcaval (TCv) to supra-aortic (SAo) approaches (transcarotid, transsubclavian, and transaxillary) for TAVR are lacking. We aimed to compare the outcomes and safety of TCv and SAo accesses for TAVR as alternatives to transfemoral TAVR. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all articles comparing TCv-TAVR against SAo-TAVR published until September 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM) and postoperative complications. A total of three studies with 318 TCv-TAVR and 179 SAo-TAVR patients were included. No statistically significant difference was found regarding in-hospital or 30-day ACM (relative risk [RR] 1.04, 95% confidence interval [CI] 0.47-2.34, p = 0.91), major bleeding, the need for blood transfusions, major vascular complications, and acute kidney injury. TCv-TAVR was associated with a non-statistically significant lower rate of neurovascular complications (RR 0.39, 95%CI 0.14-1.09, p = 0.07). These results suggest that both approaches may be considered as first-line alternatives to transfemoral TAVR, depending on local expertise and patients' anatomy. Additional data from long-term cohort studies are needed.

Transcatheter Aortic Valve Implantation Access Sites: Same Goals, Distinct Aspects, Various Merits and Demerits

Transcatheter aortic valve implantation (TAVI) has been established as a safe and efficacious treatment for patients with severe symptomatic aortic stenosis (AS). Despite being initially developed and indicated for high-surgical-risk patients, it is now offered to low-risk populations based on the results of large randomized controlled trials. The most common access sites in the vast majority of patients undergoing TAVI are the common femoral arteries; however, 10-20% of the patients treated with TAVI require an alternative access route, mainly due to peripheral atherosclerotic disease or complex anatomy. Hence, to achieve successful delivery and implantation of the valve, several arterial approaches have been studied, including transcarotid (TCr), axillary/subclavian (A/Sc), transapical (TAp), transaortic (TAo), suprasternal-brachiocephalic (S-B), and transcaval (TCv). This review aims to concisely summarize the most recent literature data and current guidelines as well as evaluate the various access routes for TAVI, focusing on the indications, the various special patient groups, and the advantages and disadvantages of each technique, as well as their adverse events.

Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access

PURPOSE

To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases.

TECHNIQUE

Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle.

CONCLUSION

Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases.

CLINICAL IMPACT

A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.

Outcomes of Alternative Access Transcatheter Aortic Valve Replacement Procedures

Alternative access transcatheter aortic valve replacement (TAVR) consists primarily of 4 different options: transcaval, transaxillary, transcarotid, and transapical. While many centers have a preferred alternative access site, few papers have compared the outcomes of TAVR with each alternative access site. In this review, we examine the outcomes of TAVR at each alternative access site, focusing on mortality, stroke, bleeding, pacemaker insertion, paravalvular leakage, and discharge to home. Notable findings include higher mortality in the transapical group and higher stroke rate in the transaxillary group. On the basis of these data, we suggest that transcarotid TAVR might represent the second choice of approach for TAVR when alternate access is required.

Transcaval Access and Closure Best Practices

Transcaval aortic access is a versatile electrosurgical technique for large-bore arterial access through the wall of the abdominal aorta from the adjoining inferior vena cava. Although counterintuitive, its relative safety derives from the recognition that interstitial hydraulic pressure exceeds venous pressure, so arterial bleeding harmlessly decompresses into the nearby caval venous hole. Transcaval access has been performed in thousands of patients for transcatheter aortic valve replacement and endovascular thoracic aneurysm repair and to avoid limb ischemia in percutaneous mechanical circulatory support. Transcaval access may have value compared with transaxillary or subclavian access and with surgical transcarotid access when standard transfemoral access is not optimal. The dissemination of transcaval access and closure techniques has been hampered by the unavailability of commercially marketed devices. This state-of-the-art review details exemplary transcaval technique, patient selection, computed tomographic planning, step-by-step access and closure, management of complications, and procedural troubleshooting in special situations. These contemporary best practices can help operators gain or maintain proficiency.

Trans-caval aspiration artherectomy/thrombectomy of large mobile plaques and thrombi in aortic arch and descending aorta

Aspiration thrombectomy with the AngioVac is approved for percutaneous removal of thrombus in the venous system. While not approved for aspiration of thrombus or other mass in the left heart or arterial system, it has been used in that setting. Patients with left heart or arterial mass are often deemed unfavorable for surgery and treated conservatively. This may not be the best option for all patients, as some may have lesions that represent a short-term increased risk of complications, for which intervention and aspiration could be considered reasonable. Unfortunately, femoral arteries sizes often cannot accommodate the Angiovac current aspiration cannula dimensions. Here, we demonstrated trans-caval approach for aspiration thrombectomy of extensive aortic mobile plaque and thrombus.

Transcaval access for the emergency delivery of 5.0 liters per minute mechanical circulatory support in cardiogenic shock

OBJECTIVES

The purpose of this study was to describe the feasibility and early outcomes of transcaval access for delivery of emergency mechanical circulatory support (MCS) in cardiogenic shock.

BACKGROUND

Vascular access for implantation of MCS in patients with cardiogenic shock is often challenging due to peripheral arterial disease and vasoconstriction. Transcaval delivery of MCS may be an alternative. We describe a series of patients we implanted an Impella 5.0 device, on-table without CT planning, through a percutaneous transcaval access route.

METHODS

Ten patients with progressive or refractory cardiogenic shock underwent Impella 5.0 implantation via transcaval access. Demographic, clinical and procedural variables and in-hospital outcomes were collected.

RESULTS

All ten underwent emergency implantation of the 7 mm diameter Impella 5.0 device via transcaval access. Six were women, with median age of 55.5 years (range, 29-69). Cardiogenic shock was attributed to idiopathic nonischemic cardiomyopathy (n = 4), myocarditis (n = 2), ischemic cardiomyopathy (n = 2), heart transplant rejection (n = 1), and unknown etiology (n = 1). Median duration of support was 92.1 hr (range, 21.2-165.4). Seven (70%) survived to device explant, with six (60%) surviving to access port closure and discharge. Among survivors, five recovered heart function and one received destination therapy left ventricular assist device.

CONCLUSIONS

Transcaval access is feasible for emergency nonsurgical implantation of the Impella 5.0 device in cardiogenic shock with small or diseased iliofemoral arteries. This allows early institution of higher-flow MCS than conventional femoral artery implantation of the 3.5 L Impella CP device, and enables a bridge-to-recovery or bridge-to-destination strategy.

Transcatheter Electrosurgery: JACC State-of-the-Art Review

Transcatheter electrosurgery refers to a family of procedures using radiofrequency energy to vaporize and traverse or lacerate tissue despite flowing blood. The authors review theory, simulations, and benchtop demonstrations of how guidewires, insulation, adjunctive catheters, and dielectric medium interact. For tissue traversal, all but the tip of traversing guidewires is insulated to concentrate current. For leaflet laceration, the "Flying V" configuration concentrates current at the inner lacerating surface of a kinked guidewire. Flooding the field with non-ionic dextrose eliminates alternative current paths. Clinical applications include traversing occlusions (pulmonary atresia, arterial and venous occlusion, and iatrogenic graft occlusion), traversing tissue planes (atrial and ventricular septal puncture, radiofrequency valve repair, transcaval access, Potts and Glenn shunts), and leaflet laceration (BASILICA, LAMPOON, ELASTA-Clip, and others). Tips are provided for optimizing these techniques. Transcatheter electrosurgery already enables a range of novel therapeutic procedures for structural heart disease, and represents a promising advance toward transcatheter surgery.

Transcaval transcatheter aortic valve replacement: a visual case review

Transcatheter aortic valve replacement (TAVR) has emerged as a viable, minimally-invasive and widely adopted approach for the treatment of severe symptomatic aortic stenosis in patients who are intermediate-risk or greater for surgical aortic valve replacement. Numerous studies have demonstrated favorable outcomes with TAVR in this population, particularly with transfemoral access TAVR. Transfemoral TAVR has been shown to be safer and associated less morbidity, shorter lengths of hospital stay and more rapid recovery as compared with traditional thoracic alternative-access TAVR (transapical or transaortic). Despite iterative advancements in transcatheter heart valve technology and delivery system, there remain a portion of patients with iliofemoral arterial vessel sizes that are too small for safe transfemoral TAVR. Paradoxically, these patients are generally higher risk and are thus less favorable candidates for open surgery or traditional alternative-access TAVR. With these considerations in mind, transcaval TAVR was developed as a fully percutaneous, non-surgical approach for aortic valve replacement in patients who are poor candidates for traditional alternative-access TAVR. In this manuscript we describe the principles on which transcaval TAVR was developed, the outcomes from the largest trial completed evaluating this technique as well as describing the technique used to perform this procedure in a case-based format.

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.

Anatomic Suitability for Transcaval Access Based on Computed Tomography

Transcaval access has been used successfully for over 200 transcatheter aortic valve replacements, large-bore percutaneous left ventricular assist devices, and thoracic endovascular aortic aneurysm repairs. This review teaches how to plan transcaval access and closure based on computed tomography. The main planning goals are to: 1) identify calcium-free crossing targets in the abdominal aorta along with optimal fluoroscopic projection angles and level with respect to lumbar vertebrae; 2) identify obstacles such as interposed bowel or pedunculated aortic atheroma; 3) plan covered stent bailout; and 4) identify jeopardized vascular branches such as renal arteries that might be obstructed by bailout covered stents if employed. The aorta and inferior vena cava are segmented (sculpted) using an image reconstruction workstation and crossing targets are highlighted. Important measurements such as aortic lumen diameter and target distance from renal arteries, aortoiliac bifurcation, and right femoral vein puncture site are reported to assist the operator. The proposed classification for transcaval feasibility has been revised, making some previously unfavorable candidates now feasible or favorable based on procedural success to date. Transcaval access allows percutaneous introduction of large devices into the aorta despite small or diseased iliofemoral arteries. By following these simplified procedures, both operators and imaging specialists can easily prepare comprehensive treatment plans.

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. This access can be vital in other situation when large bore access is needed. We described a case of 65-year-old man who had large thoracic descending aortic aneurysm with diffuse bilateral iliac disease precluding the arterial access required for the procedure. The patient underwent successful transcaval access with placement of 22-Fr balloon expandable sheath followed with successful deployments of 32 mm × 32 mm × 150 mm Valiant stent graft (Medtronic, Minneapolis, MN). The aorto-vena cava tract was closed successfully using 12 × 10 PDA occluder device with no residual flow at the end of the case, which was confirmed on repeated CT next day.

Transcaval biopsy of a mediastinal mass compressing the superior vena cava

Imaging‐guided percutaneous chest biopsy is a commonly performed procedure and considered the minimally invasive gold standard for histopathological investigation of thoracic masses. Recognized complications include pneumothorax, air embolism, and seeding of the biopsy tract. We describe a novel approach to diagnostic sampling of a mediastinal mass in a critically unwell patient using a transjugular hepatic biopsy needle. Transcaval mediastinal biopsy may represent a safer alternative to percutaneous biopsy of mediastinal masses in critically unwell patients.

Transcaval Access and Closure for Transcatheter Aortic Valve Replacement: A Prospective Investigation

BACKGROUND

Transcaval access may enable fully percutaneous transcatheter aortic valve replacement (TAVR) without the hazards and discomfort of transthoracic (transapical or transaortic) access.

OBJECTIVES

The authors performed a prospective, independently adjudicated, multicenter, single-arm trial of transcaval access for TAVR in patients who were ineligible for femoral artery access and had high or prohibitive risk of complications from transthoracic access.

METHODS

A total of 100 patients underwent attempted percutaneous transcaval access to the abdominal aorta by electrifying a caval guidewire and advancing it into a pre-positioned aortic snare. After exchanging for a rigid guidewire, conventional TAVR was performed through transcaval introducer sheaths. Transcaval access ports were closed with nitinol cardiac occluders. A core laboratory analyzed pre-discharge and 30-day abdominal computed tomograms. The Society of Thoracic Surgeons predicted risk of mortality was 9.6 ± 6.3%.

RESULTS

Transcaval access was successful in 99 of 100 patients. Device success (access and closure with a nitinol cardiac occluder without death or emergency surgical rescue) occurred 98 of 99 patients; 1 subject had closure with a covered stent. Inpatient survival was 96%, and 30-day survival was 92%. Second Valve Academic Research Consortium (VARC-2) life-threatening bleeding and modified VARC-2 major vascular complications possibly related to transcaval access were 7% and 13%, respectively. Median length of stay was 4 days (range 2 to 6 days). There were no vascular complications after discharge.

CONCLUSIONS

Transcaval access enabled TAVR in patients who were not good candidates for transthoracic access. Bleeding and vascular complications, using permeable nitinol cardiac occluders to close the access ports, were common but acceptable in this high-risk cohort. Transcaval access should be investigated in patients who are eligible for transthoracic access. Purpose-built closure devices are in development that may simplify the procedure and reduce bleeding. (Transcaval Access for Transcatheter Aortic Valve Replacement in People With No Good Options for Aortic Access; NCT02280824).

Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients: initial human experience

OBJECTIVES

This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava.

BACKGROUND

TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals.

METHODS

We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access.

RESULTS

Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract.

CONCLUSIONS

Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.