Consider the transaortic approach when faced with difficult iliofemoral anatomy

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Thomas Chollet

The first propensity-matched comparison between the transaortic approach and the transfemoral approach in patients undergoing transcatheter aortic valve implantation (TAVI) at a high-volume centre shows no significant difference in terms of 30-day and one-year mortality. These indicate that the transaortic approach should be considered when the transfemoral approach is not feasible.

Writing in EuroIntervention, Thomas Chollet (Department of Cardiology, Rangueli University Hospital, Toulouse, France) and others report that several retrospective studies and the ROUTE registry have indicated that the transaortic approach is associated with good short-term outcomes. However, they note: “Limited data are available regarding direct comparison and transfemoral aortic valve replacement and transaortic aortic valve repair in high-volume centres.” Therefore, they sought to “compare the long-term outcomes of transaortic aortic valve replacement vs. transfemoral aortic valve replacement”.

Of 644 patients who underwent TAVI between January 2012 and December 2015, 163 underwent the procedure with the transaortic approach. Of these patients, 124 were propensity matched in a 1:1 ratio with patients undergoing the transfemoral approach. The primary endpoint was 30-day and one-year mortality.

There were no significant differences between groups in the primary endpoint in either the overall population or in the propensity matched analysis. However, in the overall population, the rate of one-year mortality tended to be higher: 18.4% for transaortic vs. 15.8% for transfemoral (p=0.6).

Furthermore, the transaortic approach was associated with a higher risk of new-onset atrial fibrillation, life-threatening bleeding, and transfusion. These findings, according to Chollet et al, outline “a number of advantages of performing transfemoral aortic valve replacement rather than transaortic aortic valve replacement” and that the transfemoral approach “should remain the first access route to be considered when planning TAVI”.

However, given that the transfemoral approach is still considered unsafe in a small proportion of patients, alternative approaches are needed. According to the authors, compared with other alternative approaches (such as the transapical approach), the transaortic approach offers “several advantages” that include “high feasibility, with direct and stable access to the aortic valve”. “Furthermore, in case of haemodynamic collapse during the procedure, transaortic access enables rapid conversion to full sternotomy and rapid control of major complications such as ventricular perforation,” Chollet et al comment.

They note that the choice of alternative approach depends on factors such as local TAVI experience or the habits of surgical teams involved in the TAVI programme. However, the authors conclude: “When facing a difficult iliofemoral anatomy, heart teams should consider these comparable long-term outcomes transaortic aortic valve replacement to determine the best access site for their patients.”

Chollet told Cardiovascular News: “The main focus of our work was to show that there are no differences in mortality endpoints between transaortic and transfemoral—meaning that physicians should not hesitate to choose alternative (transaortic) access when facing challenging iliofemoral or aortic anatomy.”

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