Transcarotid Access: The Future of Non-femoral TAVR?

Research presented at TVT.19 suggested 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, said Keith B. Allen, MD, of Saint Luke’s Mid America Heart Institute in Kansas City, Mo. Sites using transcarotid access with the Sapien 3 (Edwards Lifesciences) device doubled over the last year, to more than 90 in the U.S., even as TA and TAo use declined.

“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 vs. TA/TAo access. Drawing from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry, the researchers studied 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, finding device success was “exceptionally high” in all cases. However, Allen said, transcarotid access cases went a bit quicker than TA/TAo cases.

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

Stroke rates were similar between the groups, with around 4 percent of transcarotid patients and 3 percent 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 could cut costs, based on the researchers’ findings. The transcarotid patients had shorter lengths of stay compared to the TA/TAo patients (3- vs. 6-day hospitalizations and 1 vs. 2 days in the ICU). Nearly 81 percent of the transcarotid patients were discharged from the hospital directly to their homes, while only 59 percent of the TA/TAo patients went straight home. The TA/TAo patients were more likely than the transcarotid patients to be discharged to extended care or rehab and nursing homes.

Allen noted study limitations, including use of non-adjudicated observational registry data and missing data points, such as whether interventionalists accessed the left or right carotid artery. Allen said future analysis should compare transcarotid access to subclavian and transcaval access to determine if transcarotid access is truly the best route for patients ineligible for transfemoral TAVR.