Patients undergoing TAVR using transcaval access experienced a lower risk of stroke and similar risk of bleeding when compared with those undergoing transaxillary TAVR, according to new research published May 2 in JACC: Cardiovascular Interventions. However, patients in both the transcaval and transaxillary groups experienced more complications than those undergoing TAVR with transfemoral access, researchers said.

Robert J. Lederman, MD, FACC, et al., used patient data from the STS/ACC TVT Registry from 2017 to 2020. All told, transcaval access was used in 238 procedures, transaxillary access was used in 106 and transfemoral access was used in 7,132.

Results found stroke and transient ischemic attack were significantly less common among those with transcaval access (2.5%) compared with transaxillary access (13.2%). More patients in the transcaval group were also discharged directly home and without stroke or transient ischemic attack compared with transaxillary. However, cases of major and life-threatening bleeding, as well as blood transfusion, were more comparable between the two groups. Vascular complications, ICU and hospital length of stay, and survival were also similar. 

Lederman and colleagues noted that outcomes for patients undergoing TAVR via transfemoral access were better across all areas compared with either transcaval or transaxillary access. However, based on the study findings, they suggest that transcaval TAVR “may offer an attractive option” when transfemoral access is not available. 

In an accompanying editorial, Nicolas M. Van Mieghem, MD, PhD, FACC, and Jan Tijssen, PhD, contribute their own perspective to the transcaval versus transaxillary debate, stating: “In our view, TAVR teams should first truly master one alternative (non-[transfemoral]) arterial access strategy ([transcaval], [transaxillary], or transcarotid) and ensure an adequate volume of cases to maintain expertise in that technique to be able to safely treat the overwhelming majority of patients with severe aortic stenosis. In the rare event that a patient would not be eligible for that alternative technique, it would be better to refer to a center that has mastered the other access approaches.”

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Intensive Care Units, Stroke, Arteries, Hospitals, Blood Transfusion, Registries, Aortic Valve Stenosis, Patient Discharge, Ischemic Attack, Transient, Length of Stay, Transcatheter Aortic Valve Replacement, STS/ACC TVT Registry

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