Transcarotid TAVR Is Feasible, Could Supplant Other Alternatives to Transfemoral, Group Says

Carotid access for transcatheter aortic valve replacement is a reasonable option for patients who cannot undergo the procedure by the more typical transfemoral route, with a French series suggesting it involves a low risk of cerebrovascular events.

Whether the technically demanding procedure, which is performed under general anesthesia, would have a place alongside other access routes in an era of smaller sheath sizes remains to be established. The senior author on the study, however, told TCTMD he believes carotid access may eventually supplant other, more widely accepted alternatives to transfemoral access down the road.

Darren Mylotte, MD (University Hospital Galway, Ireland), and colleagues report results for 96 TAVR patients treated via a transcarotid approach between 2009 and 2013 at three French centers in an early-online publication of JACC: Cardiovascular Interventions. All patients were elderly (mean age 79) and at high risk for surgery (mean STS score 7.1). The majority (93%) were in NYHA class III or IV heart failure.

Most procedures were performed via the left common carotid artery (89%), and most employed CoreValve (Medtronic, 93% of cases). The most common complications were device embolization (3% of cases), need for a second transcatheter valve (3%), and cardiac tamponade due to left ventricular perforation (4%). Major bleeding and major vascular complications occurred in four patients, although none of these cases involved the carotid access site, Mylotte et al note. Three patients died during their procedures and an additional three within the first 30 days. One-year mortality was 16.7%.

Of note, all patients underwent CT or magnetic resonance neuroimaging reviewed by a neurologist, and no strokes were reported. Two TIA were detected immediately postoperatively and one on day 1 postprocedure; three additional TIAs occurred within the first 30 days.

Stroke Stems From Varied Causes

Speaking with TCTMD, senior author on the study, Thomas Modine, MD (Hopital Cardiologique, Lille Cedex, France), said that concerns about stroke via carotid access are overblown.

“There is a lot of ignorance and unscientific beliefs around this access,” he said. Unlike the subclavian artery, Modine added, the carotid arteries are straight and easily accessed, particularly by cardiothoracic surgeons with aortic arch experience or vascular surgeons with carotid experience.

Timing and nature of TIA in these events—four were located contralateral to the vascular access site—suggests that there may be multiple stroke mechanisms including embolization of debris (rather than access site trauma) and/or inadequate collateral perfusion.

“We do not recommend [starting] TAVI with carotid access, but once a center has a TAVI experience, carotid access is a good friend: less invasive than other alternative access routes, rapid, and elegant,” Modine said. 

In France, he added, although transcarotid approaches do not have regulatory approval, the carotid has already surpassed subclavian as the access route of choice after transfemoral and is nearly on par with direct aortic and transapical approaches.

Moreover, there will always need to be a role for nontransfemoral TAVR, even as devices get smaller and more deliverable, Modine stressed. “Smaller devices will definitely reduce the need for alternative access,” he said. “However, the elderly patient population will increase over time and Asian populations, unlike Western, have smaller anatomies [so that] alternative access would definitely reduce the risk of vascular access problems, which are still dramatic in nonexperienced centers.”

That view appears to be supported in an accompanying editorial by Michael J. Reardon, MD, and Neal S. Kleiman, MD (Houston Methodist DeBakey Heart & Vascular Center, TX), who note that this series of patients represents the largest to date, yielding “very reasonable results for mortality and neurological events.”

Potential drawbacks of this approach, they continue, include the need for fairly extensive training within the TAVR team, including surgeons with considerable experience in carotid artery procedures; the need for general anesthesia, which “may limit sites that want to use a minimalist approach”; the valve embolization rate of 3%, which might point to awkward operator position and difficulties manipulating the equipment; and relatively long hospital stays (a median of 11 days in this series).

That said, “transcarotid access appears to have reasonable safety and efficacy profiles,” they write. “How this approach will compare with trans-subclavian, transcaval, or suprasternal direct aortic approaches is still unknown and is fertile ground for future research.”

Modine said to TCTMD that he’s seen interest growing internationally for transcarotid TAVR. Whereas in the past he found himself “fighting” and “defending” the approach, he reported now getting more requests for training and live demonstrations. “This is definitely a technique for the future,” he said, adding that the procedure has also proved feasible under local anesthetic, something that will be the focus of an upcoming paper.

Sources: 
1. Mylotte D, Sudre A, Teiger A, et al. Transcarotid transcatheter aortic valve replacement: feasibility and safety. J Am Coll Cardiol Intv. 2016; 9:472-480.
2. Reardon MJ, Kleiman NS. How many roads lead to Rome? J Am Coll Cardiol Intv. 2016;9:481-483. 

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• Transfemoral Access Not Only Option for TAVR
• French Registry Provides Window into Real-World TAVR Use