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J Am Coll Cardiol. 2017 Feb 7;69(5):511-521. doi: 10.1016/j.jacc.2016.10.024. Epub 2016 Oct 29.

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

Author information

1
Henry Ford Hospital, Detroit, Michigan.
2
Emory University, Atlanta, Georgia.
3
National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
4
Oklahoma Heart Institute, Tulsa, Oklahoma.
5
Lexington Medical Center, West Columbia, South Carolina.
6
Ochsner Medical Center, New Orleans, Louisiana.
7
National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Electronic address: lederman@nih.gov.

Abstract

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).

KEYWORDS:

caval-aortic access; nontransfemoral access; structural heart disease; transcatheter aortic valve replacement; transcaval; vascular access

PMID:
27989885
PMCID:
PMC5291753
[Available on 2018-02-07]
DOI:
10.1016/j.jacc.2016.10.024
[Indexed for MEDLINE]
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