Caval-Aortic Access May Offer a New Access Strategy for TAVR

July 1, 2014—Findings from a study on the initial human experience with caval-aortic access for transcatheter aortic valve replacement (TAVR) in otherwise ineligible patients were published by Adam B. Greenbaum, MD, et al in the Journal of the American College of Cardiology (JACC; 2014;63:2795–2804). The investigators concluded that percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients and may offer a new access strategy for other procedures utilizing large transcatheter implants.

According to the investigators, this study describes the first use of caval-aortic access and closure to enable 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. The investigators noted that TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis but the 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.

As summarized in JACC, the investigators 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. 

The investigators found that 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, two (11%) of whom required intervention. Most patients (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. 

Throughout the 111 days (range, 39–229) of follow-up, there were no postdischarge complications related to tract creation or closure. All patients had persistent aortocaval flow immediately postprocedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aortocaval tract, reported the investigators in JACC.