Extrathoracic Should Be Preferred Alternative to Transfemoral TAVI: Registry

VIENNA, Austria—More data are confirming that if femoral access isn’t possible for transcatheter aortic valve replacement, then operators should at the very least stay out of the thorax when delivering the valve, according to a new observational study.

When compared with intrathoracic vascular access, which mostly involved transapical TAVI, delivery of the transcatheter heart valve via either the axillary or carotid artery resulted in better 30-day mortality outcomes and shorter hospital stays, all without an increased risk of stroke or other safety concerns, reported investigators last week at the European Association for Cardio-Thoracic Surgery (EACTS) annual meeting.

“There’s a growing body of evidence that suggests there needs to be a shift toward the extrathoracic approach because of less perioperative complications,” said lead investigator Victor Mosquera Rodriguez, MD, PhD (Complejo Hospitalario Universitario A Coruña, Spain), during the meeting.

While their results are exploratory given the study’s observational design, transapical TAVI shouldn’t be the default alternative if transfemoral access isn’t available, said Rodriguez. “There will still be patients where the transapical approach is the only solution,” he told TCTMD. “The difference is that in 2009 and 2010, it was our first choice after the transfemoral approach.” Today, transapical access is increasingly pushed further down the list of preferred alternatives as physicians gain experience with other extrathoracic access sites, he said. 

While transfemoral vascular access for TAVI remains the gold standard, “it’s not always possible in up to 20% of cases,” said Rodriguez. Some patients may have extensive peripheral artery disease, calcifications, or tortuous common femoral or iliac arteries that don’t allow for transfemoral access, while other patients may have aneurysms in the thoracic or abdominal aorta where operators don’t feel confident given the potential risk of rupture.

The clinical guidelines make no firm recommendations on the preferred alternative access site if transfemoral TAVI isn’t possible. Historically, transapical and transaortic were the primary alternatives to transfemoral access—they are performed under general anesthesia and require surgical cutdown of the thoracic wall—but extrathoracic surgical approaches of the supra-aortic arteries (subclavian, axillary, and common carotid) were later developed and shown to be safe.

“The choice between an extrathoracic versus intrathoracic approach in non-transfemoral TAVI is not always easy,” Rodriguez told TCTMD. “Patient comorbidities, anatomy, and even the expertise of the treating center plays a role in the decision.”

Higher 30-Day Mortality, Longer Stays

The new analysis focused on non-transfemoral TAVI cases performed between 2009 and 2023 at single center in Spain. Of the 402 procedures, 279 involved intrathoracic vascular access (transapical TAVI with a balloon-expandable valve) and 123 extrathoracic access (transaxillary and transcarotid TAVI; 48 and 75 cases, respectively, with a mix of balloon- and self-expandable valves). The procedures were performed in a hybrid or conventional operating room under general anesthesia.  

Patients treated via extrathoracic access were older and had a higher prevalence of peripheral vascular disease, coronary artery disease, and higher predicted risk of mortality based on the EuroSCORE II while those undergoing intrathoracic TAVI were more likely to have had prior cardiac surgery.

In a propensity-matched analysis, 30-day mortality was significantly lower in patients treated extrathoracic access than those who had intrathoracic TAVI (1.6% vs 10.2%; P = 0.006). Hospital length of stay was also lower in those treated with extrathoracic TAVI (mean 3.9 vs 8.6 days; P < 0.001).

“It’s also worth mentioning that extrathoracic TAVI was associated with a significantly lower risk of respiratory infections and significantly fewer vascular-access complications,” said Rodriguez. Additionally, rates of low cardiac output syndrome and new-onset atrial fibrillation (AF) were lower in extrathoracic-treated patients, as was the risk of major or life-threatening bleeding. Stroke rates were similar with extrathoracic and intrathoracic TAVI (zero vs 2.4%, respectively). Postoperative hemodynamic performance was also similar between the non-transfemoral approaches.

These data, said Rodriguez, line up with findings from other studies showing better outcomes with the extrathoracic approach. In the STS/ACC TVT Registry, for example, the transcarotid approach was superior to transapical/transaortic access when it came to mortality, new-onset AF, all-cause readmissions, and quality of life. Here, too, the transcarotid approach was not associated with higher stroke risks. 

Benoy Shah, MBBS, MD (University Hospital Southampton NHS Foundation Trust, England), past president of the British Heart Valve Society, said that most operators and TAVI centers have moved away from transapical access given the poorer outcomes. “That’s also slightly unfair because those patients were always the sickest and frailest,” he told TCTMD. “If you couldn’t undergo transfemoral [TAVI], it was usually because all your other arteries were flared up or you were quite frail.”

Nonetheless, with the drawbacks of transapical access, intrathoracic TAVI with transaxillary/subclavian access is growing, said Shah. Transcarotid access is less frequently performed, he noted.

“I would add the caveat that the percentage of people who can’t undergo transfemoral TAVI is constantly going down,” said Shah, noting that some operators are performing peripheral vascular interventions ahead of TAVI. For example, use of intravascular lithotripsy (Shockwave Medical) has allowed operators to treat iliofemoral disease and facilitate transfemoral TAVI. Others are placing iliac arterial stents in severely stenosed arteries to allow passage of the transcatheter valve to the heart.

To TCTMD, Rodriguez said the transcarotid approach is the preferred alternative route over transaxillary access at their site, noting that their training programs shifted in 2020 to preference this approach. Surgeons, he said, feel the carotid artery is quite similar to the aorta, an artery where they are already quite confident. However, he understands there is some trepidation with this approach, the biggest concern being the risk of stroke, but pointed out they did not see any signal of harm with this access site.