Caval-Aortic Access to Allow Transcatheter Aortic Valve Replacement in Otherwise Ineligible Patients: Initial Human Experience

• Published in: Journal of the American College of Cardiology 2014-07, Vol.63 (25), p.2795-2804
• Main Authors: GREENBAUM, Adam B, O'NEILL, William W, PAONE, Gaetano, GUERRERO, Mayra E, WYMAN, Janet F, COOPER, R. Lebron, LEDERMAN, Robert J
• Format: Article
• Language: English
• Subjects: Aged, 80 and over; Angiography; Aorta, Thoracic; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - surgery; Biological and medical sciences; Cardiac Catheterization - methods; Cardiology. Vascular system; Female; Fluoroscopy; Follow-Up Studies; Heart; Heart Valve Prosthesis Implantation - methods; Humans; Male; Medical sciences; Retrospective Studies; Risk Assessment - methods; Severity of Illness Index; Tomography, X-Ray Computed; Treatment Outcome; Venae Cavae
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2014.04.015

This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access. Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract. Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.