Caval-Aortic Access to Allow Transcatheter Aortic Valve Replacement in Otherwise Ineligible Patients

• Published in: Journal of the American College of Cardiology Vol. 63; no. 25; pp. 2795 - 2804
• Main Authors: Greenbaum, Adam B., MD, O'Neill, William W., MD, Paone, Gaetano, MD, Guerrero, Mayra E., MD, Wyman, Janet F., DNP, Cooper, R. Lebron, MD, Lederman, Robert J., MD
• Format: Journal Article
• Language: English
• Published: New York Elsevier Inc 01-07-2014; Elsevier Limited
• Subjects: Cardiology; Cardiovascular; Cardiovascular disease; Catheters; caval-aortic; Chronic obstructive pulmonary disease; Coronary vessels; extra-anatomic procedures; Frailty; Heart; Heart attacks; Internal Medicine; Mortality; Patients; transcatheter aortic valve replacement; transcaval; California; computed tomography; aortic valve replacement; transcaval; caval-aortic; ADO; Amplatzer muscular ventricular septal defect occluder; TAVR; MVSDO; CT; inferior vena cava; extra-anatomic procedures; IVC; transcatheter aortic valve replacement; Amplatzer duct occluder; AVR
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2014.04.015

Objectives 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. Background 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. Methods We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access. Results 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. Conclusions 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.