麻豆传媒

Transcatheter aortic valve replacement (TAVR) can be done through the carotid artery and is relatively less challenging for patients ill-suited to the typical transfemoral approach, a French registry study suggested.

Procedural mortality occurred in , with a 30-day rate of stroke or transient ischemic attack of 6.3%, , of Hôpital Cardiologique in Lille, France, and colleagues found.

In addition, death was recorded for 6.3% of patients by 30 days. By 1 year, that figure had grown to 16.7%, which exceeded the predicted mortality of 7.1%, the researchers reported in JACC: Cardiovascular Interventions.

Other complications included valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeding events or major vascular complications related to the access site, but moderate-to-severe aortic regurgitation occurred in 21.5% of patients.

Still, "transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes," Modine's group wrote, adding that "transcarotid TAVR is technically feasible in appropriately-selected patients" as "carotid vascular access site complications are rare."

"We believe that transcarotid TAVR should be considered as an alternative to transapical, transortic, transcaval, or trans-subclavian procedures," they wrote, reasoning that such an approach is technically less challenging, requiring no thoractomy or sternotomy. "The surgical approach to the carotid artery is relatively uncomplicated due to its superficial location, and operative experience with the carotid arteries is widely available among cardiovascular surgeons," they added.

It is generally accepted that approaches that cross the thoracic wall are likely to cause less physiological stress -- facilitating quicker recovery -- , and , both of Houston Methodist DeBakey Heart & Vascular Center, acknowledged in accompanying editorial.

However, despite Modine's favorable results, transcarotid TAVR does have potential drawbacks. "Fairly extensive TAVR team training is required, and one assumes that the surgeons performing the procedure had considerable experience managing carotid artery surgery," the pair wrote.

The prospective study included 96 patients from the French Transcarotid TAVR Registry.

Citing the relatively high 30-day mortality rate of 6.3%, the authors noted that their "patient cohort was unsuitable for transfemoral TAVR, and thus the mean Society of Thoracic Surgeons predicted risk of mortality score of 7.1% may underestimate the true risk features of this group." They added that their complications reflect a learning curve as well.

The editorialists agreed that "it is also difficult to dissect patient acuity from procedural risk in such a report," given that there was an evolution in TAVR over the course of the study.

On the other hand, the investigators attributed the low stroke rate to patient selection, mandatory pretreatment with dual antiplatelet therapy, sufficient intraoperative anticoagulation, and placement of the large bore introducer sheath only when necessary.

Though the study described the largest cohort of transcarotid TAVR patients to date, it was limited by the small sample size. What's more, "it is possible that the true rate of neurological events has been underestimated, as systematic evaluation by a neurologist was not performed prior to and following TAVR," Modine and colleagues added.

Reardon and Kleiman also believed that "the major question" still looming is the neurological safety of the transcarotid approach.

And with regard to valve embolization, "one wonders whether the awkward operator positions required to insert a prosthesis through the transcarotid approach limit manipulation of the equipment," the editorialists wrote.

"It is likely that the proportion of patients undergoing TAVR using alternate vascular access routes will fall due to advances in transcatheter technology; however, these technologies are not yet available worldwide, and patients with severe peripheral arterial disease will remain a considerable challenge for transfemoral access regardless of sheath size," Modine's group wrote.

"How this approach will compare with trans-subclavian, transcaval, or suprasternal direct aortic approaches is still unknown and is fertile ground for future research," Reardon and Kleiman concluded.