Alternative vascular access for Transcatheter Aortic Valve Replacement (TAVR), analysis from the Israeli transcatheter aortic valve replacement registry

Introduction: TAVR is a reliable therapy for patients with severe aortic stenosis. Femoral artery is the default access route for TAVR; however, when this route is precluded several alternative routes are available. Our aim was to compare patients’ characteristics and outcomes in alternative approach TAVR.

Materials and methods: We retrospectively analyzed the Israeli multicenter registry, during 2008-2019. Transapical or axillary access cases were compared to femoral artery ones. Direct-aortic and trans-caval approaches were too rare to be analyzed.

Results and discussion: A total of 4192 TAVRs were analyzed, femoral access (N=3949), transapical (N=153) and axillary (N=90). There was a clear trend towards increased femoral approach preference (85.12% in 2008-2011 vs. 97.72% in 2016-2019).
Alternative access patients had significantly higher rates of co-morbidities and higher STS scores (6.78 vs. 4.54, p-value<0.001).
Serious complications were more common in alternative access cases, including conversion to open surgery, stroke, acute kidney injury, new onset atrial fibrillation and development of heart-failure. However, the rates of vascular complications and new LBBB were higher following femoral approach. 30-days,1- and 5-years survival rates were higher for femoral artery access (all p <0.001).
Comparing transapical to axillary approach, transapical had significantly higher immediate complications including use of mechanical hemodynamic support, need for resuscitation and acute need for dialysis. 30-days survival rate were significantly worse for transapical approach (90.8% vs. 98.9%, p =0.01). Nevertheless, 1- and 5-years survival rates were not significantly different.

Conclusion: Alternative access approach TAVR is associated with increased morbidity and mortality. Although transapical approach has a higher post procedural mortality rate, 1- and 5-years survival rate are similar to the axillary approach.