Transcarotid access: The future of non-femoral TAVR?

Research presented at TVT 2019 in Chicago last week suggests a transcarotid approach to transcatheter aortic valve replacement (TAVR) is favorable for patients unable to tolerate femoral access, topping both transapical (TA) and transaortic (TAo) approaches as the preferable route for alternate-access TAVR.  

While transcarotid access isn’t the most popular option for TAVR, it’s growing in use, Keith B. Allen, MD, of Saint Luke’s Mid America Heart Institute in Kansas City, Mo., said at the conference. While TA and TAo use is declining, sites utilizing transcarotid access with the Sapien 3 (Edwards) device doubled over the last year, to more than 90 sites in the U.S.

“The need for non-femoral access during TAVR will continue to decrease as transcatheter heart size and deliverability is optimized,” Allen said. “However, as the pool of patients that require alternative access decreases, the complexity of those patients will increase, requiring the heart team to have comparative data between alternate access routes.”

Allen and his team studied outcomes following TAVR with a balloon-expandable Sapien 3, comparing results between transcarotid access and TA/TAo. Drawing from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry, the researchers enrolled 457 transcarotid patients across 88 sites and 914 TA/TAo patients across 270 sites. The population as a whole exhibited very high STS risk, but transcarotid patients tended to be more obese and have more prior PCI than TA/TAo patients, who had a higher incidence of carotid stenosis and porcelain aortas than their counterparts.

The researchers conducted a population-adjusted propensity-matched analysis of the population, finding device success was “exceptionally high” in all cases. However, Allen said, transcarotid access cases went a little bit quicker than TA/TAo cases.

The majority of 30-day stats were favorable for transcarotid patients—all-cause mortality was significantly lower in transcarotid patients (4.6% vs. 8.2% in TA/TAo patients), as was new-onset atrial fibrillation (1.6% vs. 12.1%, respectively) and all-cause readmissions (10.2% vs. 17%, respectively).

Stroke rates were similar between groups, with around 4% of transcarotid patients and 3% of TA/TAo patients experiencing an event.

“Alternate access options that mimic the results of transfemoral TAVR don’t violate the thoracic cavity, provide the straightest path to the aortic valve and are simple, cost-effective and desirable,” Allen said. “Transcarotid access appears to fit that description.”

An increase in transcarotid cases would indeed cut down on costs, since Allen et al. found a significant benefit in length of stay (LOS) in transcarotid patients compared to TA/TAo patients. Transcarotid patients were hospitalized for an average of three days, compared to six days in TA/TAo patients, and ICU LOS was one day for transcarotid patients and two days for TA/TAo patients.

Further, the majority of transcarotid patients—nearly 81%—were discharged from the hospital directly to their homes, which was the case in just 59.3% of TA/TAo patients. More TA/TAo patients were also discharged to extended care or rehab (24.9% compared to 12.7% of transcarotid patients) and nursing homes.

Allen said he and his colleagues’ work had a few limitations, including the fact that despite risk adjustment, the team’s findings were derived from observational registry data with procedural and outcomes data that hadn’t been adjudicated. Additionally, the registry they used failed to provide some data points that could have been useful, like whether interventionalists accessed the left or right carotid artery and how they performed the surgery.

An additional analysis comparing transcarotid access to subclavian and transcaval access is warranted, Allen said, to determine if transcarotid access is truly the best route for patients unable to go through with transfemoral TAVR.

“We need to determine what is the preferred alternate access, and I think this data supports transcarotid as that access choice,” he said.