Transbrachial Secondary Vascular Access in Transcatheter Aortic Valve Replacement Procedures. A Single Center Experience

Background : Transcatheter aortic valve replacement (TAVR) is preferably performed as a minimally invasive totally percutaneous transfemoral (TF) procedure. The valve is delivered via the femoral artery and secondary vascular access is required for aortography, coronary access or vascular repair of femoral artery injury if necessary. Utility of the contralateral femoral artery as the secondary access site may be limited due to peripheral vascular disease, and in some cases a third access site is required. The role of transbrachial vascular access in TAVR procedures has not been reported.

Methods : We analyzed our prospective institutional TAVR registry and identified patients who underwent TF-TAVR between 2010 and 2020, in whom transbrachial vascular access was used. Clinical characteristics, procedural data and clinical outcomes were studied.

Results : A total of 824 TAVR procedures were performed. Forty-four (5%) patients who underwent TF-TAVR using transbrachial secondary access were identified (age 80.0±7 years; 48% female; 3 cases of concomitant TAVR and EVAR). The contralateral femoral artery was not suitable for vascular access due to occlusive atherosclerosis (17), inability to cross over via the aortic bifurcation (9), stenosis of the abdominal aorta (5) and morbid obesity (6). Transbrachial access was used for angiography of the primary vascular access (24), femoral artery stenting (5), aortography (24) and coronary angioplasty (3). Satisfactory outcome of valve replacement was achieved in all cases. Brachial sheaths were removed at the end of the procedure by manual compression. Two patients sustained brachial artery occlusion requiring vascular surgery and 2 additional patients developed mild arm ischemia which was treated conservatively. There was no 30-day mortality and 1-year mortality was 14%.

Conclusion :Transbrachial secondary vascular access was used in a cohort of patients with challenging vascular anatomy and peripheral vascular disease. Use of the the brachial artery was safe and enabled a totally percutaneous valve replacement procedure.