Transcaval Aortic Access for Percutaneous Thoracic Aortic Aneurysm Repair: Initial Human Experience

Uflacker, Andre; Lim, Scott; Ragosta, Michael; Haskal, Ziv J.; Lederman, Robert J.; Kern, John A.; Upchurch, Gilbert R.; Huber, Timothy C.; Angle, John F.; Ailawadi, Gorav

doi:10.1016/j.jvir.2015.07.024

Cited by 27 publications

(28 citation statements)

References 9 publications

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“…Transcaval access is reported in only one thoracic endovascular aneurysm repair so far . In this reported case the TEVAR was performed successfully with a type I endoleaks that resolved in 1 week.…”

Section: Discussionmentioning

confidence: 80%

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access

Fanari

Hammami

Goswami

et al. 2017

Cathet Cardio Intervent

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Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. This access can be vital in other situation when large bore access is needed. We described a case of 65-year-old man who had large thoracic descending aortic aneurysm with diffuse bilateral iliac disease precluding the arterial access required for the procedure. The patient underwent successful transcaval access with placement of 22-Fr balloon expandable sheath followed with successful deployments of 32 mm × 32 mm × 150 mm Valiant stent graft (Medtronic, Minneapolis, MN). The aorto-vena cava tract was closed successfully using 12 × 10 PDA occluder device with no residual flow at the end of the case, which was confirmed on repeated CT next day.

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Section: Discussionmentioning

confidence: 80%

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access

Fanari

Hammami

Goswami

et al. 2017

Cathet Cardio Intervent

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“…It has been employed successfully as part of thoracic endovascular aneurysm repair (24) and to introduce 5.0 L percutaneous left ventricular assist devices ( Impella , Abiomed) (25). The transcaval approach may allow transcatheter implantation of other large devices, for example to treat aortic regurgitation.…”

Section: Discussionmentioning

confidence: 99%

Transcaval Access and Closure for Transcatheter Aortic Valve Replacement

Greenbaum

Babaliaros

Chen

et al. 2017

Journal of the American College of Cardiology

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192

124

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Background Transcaval access may enable fully percutaneous transcatheter aortic valve replacement (TAVR) without the hazards and discomfort of transthoracic (transapical or transaortic) access. Objectives We performed a prospective, independently-adjudicated, multi-center, single-arm Investigational Device Exemption trial of transcaval access for TAVR in patients ineligible for femoral artery access and high or prohibitive risk of complications from transthoracic access. Methods 100 subjects underwent attempted percutaneous transcaval access to the abdominal aorta by electrifying a caval guidewire and advancing 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 lab analyzed pre-discharge and 30-day abdominal CT. The STS predicted risk of mortality was 9.6 ± 6.3%. Results Transcaval access was successful in 99/100 subjects. Device success (access and closure with a nitinol cardiac occluder without death or emergency surgical rescue) was 98/99, except for one closed only with a covered stent. Inpatient survival was 96% and 30-day survival was 92%. VARC2 life-threatening bleeding and modified VARC2 major vascular complications possibly related to transcaval access were 7% and 13%, respectively. Median length of stay was 4 (2–6) days. There were no vascular complications after discharge. Conclusion Transcaval access enabled TAVR in patients who were not good candidates for transthoracic access. Bleeding and vascular complications, using permeable nitinol cardiac occluders to close the access ports, were common but acceptable in this high risk cohort. 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. Clinical trial NCT02280824 on clinicaltrials.gov

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“…Transcaval access has been applied to other applications, including large-bore percutaneous left ventricular assist devices for cardiogenic shock as well as thoracic endovascular aortic aneurysm repairs (1). Enrollment in the 100-subject National Heart, Lung, and Blood Institute–sponsored transcaval TAVR investigational device exemption protocol is now complete and results will be reported soon after follow-up is completed (NCT02280824).…”

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confidence: 99%

Anatomic Suitability for Transcaval Access Based on Computed Tomography

Lederman

Greenbaum

Rogers

et al. 2017

JACC: Cardiovascular Interventions

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Transcaval access has been used successfully for over 200 transcatheter aortic valve replacements, large-bore percutaneous left ventricular assist devices, and thoracic endovascular aortic aneurysm repairs. This review teaches how to plan transcaval access and closure based on computed tomography. The main planning goals are to: 1) identify calcium-free crossing targets in the abdominal aorta along with optimal fluoroscopic projection angles and level with respect to lumbar vertebrae; 2) identify obstacles such as interposed bowel or pedunculated aortic atheroma; 3) plan covered stent bailout; and 4) identify jeopardized vascular branches such as renal arteries that might be obstructed by bailout covered stents if employed. The aorta and inferior vena cava are segmented (sculpted) using an image reconstruction workstation and crossing targets are highlighted. Important measurements such as aortic lumen diameter and target distance from renal arteries, aortoiliac bifurcation, and right femoral vein puncture site are reported to assist the operator. The proposed classification for transcaval feasibility has been revised, making some previously unfavorable candidates now feasible or favorable based on procedural success to date. Transcaval access allows percutaneous introduction of large devices into the aorta despite small or diseased iliofemoral arteries. By following these simplified procedures, both operators and imaging specialists can easily prepare comprehensive treatment plans.

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Transcaval Aortic Access for Percutaneous Thoracic Aortic Aneurysm Repair: Initial Human Experience

Cited by 27 publications

References 9 publications

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access

Transcaval Access and Closure for Transcatheter Aortic Valve Replacement

Anatomic Suitability for Transcaval Access Based on Computed Tomography

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