Transcarotid Access Versus Transfemoral Access for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Background: The transfemoral (TF) route is the gold-standard access for transcatheter aortic valve replacement (TAVR). In 10-15% of patients, alternative accesses are needed, such as the transcarotid (TC) access. We performed a meta-analysis to compare 30-day mortality and complications between TC-TAVR and TF-TAVR. Methods: We searched PubMed/MEDLINE and EMBASE from inception to January 2021 to identify articles comparing TC-TAVR and TF-TAVR. Patients' baseline characteristics, procedural outcomes, and clinical 30-day outcomes were extracted. Results: We identified 9 studies, among which 2 used propensity-score matching, including 1,374 TC patients and 3,706 TF patients. TC-TAVR was associated with significantly higher EuroSCORE II and Logistic EuroSCORE values (respectively 8.0 ± 6.7 vs. 6.3 ± 5.4, p = 0.002 and 20.8 ± 14.2% vs. 20.0 ± 13.4%, p = 0.04), a higher prevalence of peripheral artery disease (52.6 vs. 32.8%, p = 0.001), previous cardiac surgery (26.3 vs. 22.4%, p = 0.008) and coronary artery disease (64.6 vs. 60.5%, p = 0.020). The pooled results found TC-TAVR to be associated with a significantly higher 30-day mortality risk (RR, 1.41, 95% CI, 1.02-1.96, p = 0.040), and a lower rate of 30-day major vascular complications (RR, 0.48, 95% CI, 0.25-0.92, p = 0.030). No significant difference was found regarding permanent pacemaker implantation, major bleeding and acute kidney injury. A subgroup analysis of the two propensity-score matched studies found a statistically increased risk of 30-day neurovascular complications (RR, 1.61, 95% CI, 1.02-2.55, p = 0.040). Conclusion: Compared with TF-TAVR, TC-TAVR was associated with an increased risk of 30-day mortality, likely related to a higher surgical risk and comorbidity burden, and with an increased risk of 30-day neurovascular complications. Careful preprocedural patient selection and close periprocedural neurological monitoring are paramount.

The transcervical access for transcatheter aortic valve replacement.

Alternative accesses for transcatheter aortic valve replacement (TAVR) are needed in a certain number of patients, who present contraindications to the standard transfemoral access. We present the transcervical approach, which allows to access the aortic valve via supra-aortic vessels, namely, the brachiocephalic trunk, carotid artery, or subclavian artery. This approach is interesting because it avoids thoracotomy, which is necessary with some other alternative approaches for TAVR, such as the transaortic or transapical ones. Although some points still need clarification, such as the best anesthesia modality (general or local) or the optimal side for vessel access, data suggest the transcervical access might yield similar periprocedural and 30-day outcomes compared with the transfemoral access. Herein, we describe the surgical technique that was developed in our institution for transcervical access.

Transapical approach versus transcervical approach for transcatheter aortic valve replacement: a retrospective monocentric study.

OBJECTIVES: Transfemoral approach is the standard access-route for transcatheter aortic valve replacement (TAVR). However, alternative approaches are needed in a number of patients and accesses such as transapical (TA) TAVR or transcervical (TC) are used. We aimed to compare clinical and echocardiographic outcomes after TA-TAVR or TC-TAVR. METHODS: All patients who underwent TA- and TC-TAVR for severe aortic stenosis in our institution between 2008 and 2020 were retrospectively included. End points included 30-day all-cause mortality, procedural complications (according to the Valve Academic Research Consortium-2 criteria), procedure duration, intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. For 30-day all-cause mortality, we furthermore used a Cox proportional-hazards model to adjust for significant between-group differences in baseline characteristics as well as difference in year of intervention. RESULTS: TAVR was performed in 176 patients, using a TA approach (n = 127) or a TC approach (n = 49). Baseline clinical and echocardiographic characteristics were comparable between the 2 groups, except age and peripheral artery disease. All-cause 30-day mortality rates were not significantly different (8.5% in the TA group vs 2.3% in the TC group, P = 0.124). TC approach was associated with significantly shorter procedure duration {71.0 [interquartile range (IQR) 52.5-101.0] vs 93 [IQR 80.0-120.0] min, P < 0.001}, shorter ICU LOS [0.0 (IQR 0.0-0.0) vs 1.0 (IQR 1.0-3.0) days, P < 0.001] and shorter hospital LOS [7.0 (IQR 5.0-9.5) vs 14.0 (IQR 10.0-22.0) days, P < 0.001]. CONCLUSIONS: The TC approach may be a good first-choice alternative in case of contraindications to transfemoral-TAVR.

Elective ostial left main stenting: a tailored approach.

Elective left main (LM) stenting is increasingly performed as a valuable alternative to coronary artery bypass grafting. Nevertheless, clinical data are limited to registries, and randomized trials have not been published. Intravascular ultrasound (IVUS) has been recognized as an accurate tool for assessing optimal stent deployment. We hereby report the usefulness of IVUS in defining the interventional strategy in four consecutive patients presenting with severe, symptomatic ostial LM disease, and this in the era of drug-eluting stents. The first two patients were treated by a short drug-eluting stent for a critical LM stenosis as IVUS demonstrated a reference diameter < 3.7 mm. The third patient had a larger reference diameter and was treated with conventional stenting with optimization of the result by IVUS. IVUS was particularly helpful in all patients to confirm accurate stent placement in relation to the LM ostium and bifurcation. In another patient, based on IVUS findings, surgery was preferred. This patient with diabetes as a risk factor presented with comparable angiographic features. IVUS, however, showed diffuse disease without any healthy reference segment in the LM. All stented patients are asymptomatic at 15 +/- 7 months follow-up with negative stress testing. The present observation indicates that IVUS is an essential tool for strategic selection and to optimize percutaneous coronary intervention for LM disease.

Clinical outcome following combination of cutting balloon angioplasty and coronary beta-radiation for in-stent restenosis: a report from the RENO registry.

At present, vascular brachytherapy is the only efficient therapy for in-stent restenosis. Nevertheless, edge restenosis often related to geographical miss has been identified as a major limitation of the technique. The non-slippery cutting balloon has the potential to limit vascular barotraumas, which, together with low-dose irradiation at both ends of the radioactive source, are the prerequisite for geographical miss. This prospective study aimed to examine the efficacy of combining cutting balloon angioplasty and brachytherapy for in-stent restenosis. The Radiation in Europe NOvoste (RENO) registry prospectively tracked all patients who had been treated by coronary beta-radiation with the Beta-Cath System (Novoste Corporation, Brussels, Belgium) but were not included in a randomized radiation trial. A subgroup of patients with in-stent restenosis treated by cutting balloon angioplasty and coronary beta-radiation (group 1, n = 166) was prospectively defined, and clinical outcomes of patients at 6 months were compared with those of patients treated by conventional angioplasty and coronary beta-radiation (group 2, n = 712). At 6-month follow-up, there was a significant difference between groups 1 and 2 in target vessel revascularization (10.2% versus 16.6% respectively; p = 0.04) and in the incidence of major adverse clinical events (MACE) including death, myocardial infarction, and revascularization (10.8% versus 19.2%; p = 0.01). This observation was confirmed by a multivariate analysis indicating a lower risk for MACE at 6 months (odds ratio: 0.49; confidence intervals: 0.27 0.88; p = 0.02). Compared to conventional angioplasty, cutting balloon angioplasty prior to coronary beta-radiation with the Beta-Cath System seems to improve the 6-month clinical outcome in patients with in-stent restenosis.

Repeated intracoronary beta radiation for recurrent in-stent restenosis.

More than 70% of percutaneous coronary interventions are followed by a stent implantation. In-stent restenosis still occurs in 20-30% of patients and remains a therapeutic challenge. At present only vascular brachytherapy has been shown to be an effective treatment option. We report here one case of recurrent in-stent restenosis after vascular brachytherapy that was successfully treated by a second beta radiation treatment.