Transcaval Access and Closure Studied for TAVR

January 30, 2017—Adam B. Greenbaum, MD, et al conducted an investigation to determine if transcaval access could enable fully percutaneous transcatheter aortic valve replacement (TAVR) without the hazards and discomfort of transthoracic (transapical or transaortic) access. The prospective, independently adjudicated, multicenter, single-arm trial investigated transcaval access for TAVR in patients who were ineligible for femoral artery access and had high or prohibitive risk of complications from transthoracic access. The findings from the study were published in the Journal of the American College of Cardiology (JACC;2017;69:511–521).

As summarized in JACC, a total of 100 patients underwent attempted percutaneous transcaval access to the abdominal aorta by electrifying a caval guidewire and advancing it into a prepositioned aortic snare. After exchanging for a rigid guidewire, conventional TAVR was performed through transcaval introducer sheaths. Transcaval access ports were closed with nitinol cardiac occluders. A core laboratory analyzed predischarge and 30-day abdominal computed tomograms. The Society of Thoracic Surgeons predicted risk of mortality was 9.6% ± 6.3%.

The investigators reported that transcaval access was successful in 99 of 100 patients. Device success (access and closure with a nitinol cardiac occluder without death or emergency surgical rescue) occurred in 98 of 99 patients; one patient in the study had closure with a covered stent. Inpatient survival was 96%, and 30-day survival was 92%. Second Valve Academic Research Consortium (VARC-2) life-threatening bleeding and modified VARC-2 major vascular complications, possibly related to transcaval access, were 7% and 13%, respectively. Median length of stay was 4 days (range, 2–6 days). There were no vascular complications after discharge.

The investigators concluded that transcaval access enabled TAVR to be performed in patients who were not good candidates for transthoracic access. In this high-risk cohort, bleeding and vascular complications, using permeable nitinol cardiac occluders to close the access ports, were common but acceptable. Transcaval access should be investigated in patients who are eligible for transthoracic access; purpose-built closure devices are in development that may simplify the procedure and reduce bleeding, advised the investigators in JACC.