Transcatheter aortic valve replacement in obese patients: procedural vascular complications with the trans-femoral and trans-carotid access routes

Abstract

OBJECTIVES Obesity may increase the risk of vascular complications in transfemoral (TF) transcatheter aortic valve replacement (TAVR) procedures. The transcarotid (TC) approach has recently emerged as an alternative access in TAVR. We sought to compare vascular complications and early clinical outcomes in obese patients undergoing TAVR either by TF or TC vascular access. METHODS Multicentre registry including obese patients undergoing TF- or TC-TAVR in 15 tertiary centres. All patients received newer-generation transcatheter heart valves. For patients exhibiting unfavourable ileo-femoral anatomic characteristics, the TC approach was favoured in 3 centres with experience with it. A propensity score analysis was performed for overcoming unbalanced baseline covariates. The primary end point was the occurrence of in-hospital vascular complications (Valve Academic Research Consortium-2 criteria). RESULTS A total of 539 patients were included, 454 (84.2%) and 85 (15.8%) had a TF and TC access, respectively. In the propensity-adjusted cohort (TF: 442 patients; TC: 85 patients), both baseline and procedural valve-related characteristics were well-balanced between groups. A significant decrease in vascular complications was observed in the TC group (3.5% vs 12% in the TF group, odds ratio: 0.26, 95% CI: 0.07–0.95, P = 0.037). There were no statistically significant differences between groups regarding in-hospital mortality (TC: 2.8%, TF: 1.5%), stroke (TC: 1.2%, TF: 0.4%) and life-threatening/major bleeding events (TC: 2.8%, TF: 3.8%). CONCLUSIONS In patients with obesity undergoing TAVR with newer-generation devices, the TC access was associated with a lower rate of vascular complications. Larger randomized studies are warranted to further assess the better approach for TAVR in obese patients.

Comparison of Alternative Peripheral and Transfemoral Approaches for Transcatheter Aortic Valve Replacement: A Meta-Analysis of Propensity-Matched Studies

“…We attempted to account for this underlying diference by including only propensity-matched studies, but unmeasured diferences between the AP and TF populations are still likely to infuence outcomes in the absence of randomization. Notably, the diference in mortality was dependent on the inclusion of 3 studies and did not persist on "leave-one-out" analysis [8,9,11]. While there was a trend towards fewer major vascular complications in AP access, this diference was not significant.…”

“…Tere were signifcantly lower rates of mortality (3.3% vs. 4.4%; OR 0.69; 95% CI [0.51, 0.94]; P � 0.02) and stroke (1.9% vs. 3.5%; OR 0.60; 95% CI [0.43, 0.84]; P � 0.003) in the TF group with low (I 2 � 5%) and no (I 2 � 0%) heterogeneity, respectively. Te diference in mortality was not signifcant on "leaveone-out" analysis when the studies by Alperi et al were individually excluded [8,9,11].…”

“…After the removal of duplicates and review of titles and abstracts, we assessed 103 articles for full-text content. Among those fully assessed, 96 articles were deemed ineligible, and 7 eligible studies were included for meta-analysis [8][9][10][11][12][13][14] (Figure 1). An overview of these studies is presented in Table 1.…”

“…Clinical outcomes from these studies were extracted and pooled for analysis, as demonstrated in Supplemental Table 2. Of the seven studies, two articles compare combined AP vs. TF access [9,14], one article compares TC vs. TF access [8], and four articles compare TAx vs. TF access [10][11][12][13].…”

Feasibility of transcaval access TAVI in morbidly obese patients: A single‐center experience

“…They reported no deaths, valve reinterventions, or reoperations. The second study compares the outcomes of 85 morbidity patients who underwent TAVI via transcarotid access to 454 patients via the transfemoral access route 14 . The transfemoral group had higher rates of vascular complications albeit with no significant difference in mortality, stroke, or life‐threatening or major bleeding.…”