The Carotid Artery as a Preferred Alternative Access Route for Transcatheter Aortic Valve Replacement

Background. In high-risk patients with severe aortic stenosis, transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) is the preferred access route but is not always feasible. Compared with other alternative access routes, transcarotid (TC) access is often overlooked by many valvular heart teams. Methods. We report our single-center experience of all patients undergoing TC (n = 25), transapical (TA) (n = 12), or TF (n = 100; limited to most recent cases) TAVR over a 1.5 year period. In-hospital and 30-day outcomes were retrospectively compared between groups using the Kruskal-Wallis and Wilcoxon rank sum tests. Results. TAVR was successfully performed through the left or right carotid artery in all 25 patients. Procedurally, TC and TF procedures were faster than TA procedures (p < 0.001), and patients who underwent TC and TF procedures had shorter intensive care unit (ICU) hours (p = 0.05), ventilator hours (p < 0.001), and length of stay (LOS) (p = 0.01) compared to patients who underwent a TA procedure. No patients who underwent a TC procedure had in-hospital stroke, transient ischemic attack (TIA), or myocardial infarction (MI). One patient who underwent a TC procedure had a TIA by 30-day follow-up, which was not significantly different from the TF (2 patients) or TA groups (0 patients; p = 0.75). In-hospital mortality rates were the same between TC (1 patient) and TF (1 patient) procedures but were significantly greater for TA procedures (2 patients; p = 0.009). Thirty-day mortality rates were low and did not differ between the groups. Conclusions. In our US community hospital setting, TC-TAVR is a safe alternative to TF-TAVR in appropriate patients and has evolved to be our alternative access route of choice if TF access is not feasible. (C) 2017 by The Society of Thoracic Surgeons