Transcarotid trancatheter aortic valve implantation under local anesthesia in real life, a retrospective observational comparison with femoral access
Authors: Trimech T.R , El Jourdi B , Fradi S , Ghostine S 
Published: November 2020

Abstract

Background
Trans-femoral approach is the most commonly used access for trans-catheter aortic valve implantation (TAVI). However, in case of unsuitability, several alterative access routes have been described, namely trans-axillary, trans-aortic and trans-apical. The trans-carotid approach, rarely used, can be of particular help.

Purpose
To compare trans-carotid with trans-femoral access for TAVI, regarding epidemiological, clinical, procedural features and in hospital prognosis.

Methods
We retrospectively analyzed the data of 1272 patients treated with TAVI between January 2013 and December 2019. Patients were divided into 2 groups and compared according to the vascular approach: trans-carotid group (n=84) and trans-femoral group (n=1188).

Results
The trans-carotid group, representing 6.6% of all patients undergoing TAVI, had significantly more hypertension (89.9% vs 75.8%; p=0.002), history of coronary artery disease (78.6% vs 50.5%; p&lt;0.001), peripheral arteriopathy (58.7% vs 9.3%; p&lt;0.0001), ischemic stroke (24% vs 10.5%; p=0.03), chronic obstructive pulmonary disease (30.8% vs 18.4%; p=0.004), surgical aortic valve replacement (12% vs 4.3%; p=0.008) and contralateral carotid endarterectomy (4% vs 0.4%; p=0.012). Average scores of LOGISTIC EUROSCORE and EUROSCORE II were significantly higher in this group (respectively 22.4 vs 15.2 and 8.3 vs 5.56; p&lt;0.0001) and patients were more frequently considered by the Heart Team as at high surgical risk (91.3% vs 68.2%; p&lt;0.0001).
When performing TAVI, balloon predilatation and postdilatation were significantly less frequent in the trans-carotid group (respectively 13.3% vs 26.4%; p=0.03 and 21.7% vs 37.6%; p=0.006). However, there was no significant difference between the 2 groups concerning neither the implantation of self-expanding/balloon-expandable valves nor in the fluoroscopy time and dose-area product averages. On post-procedural echocardiographic findings, transaortic mean gradient average and the incidence of significant paravalvular leak were similar.
During intra-hospital follow-up, patients in the trans-carotid group had significantly less vascular complications (9.3% vs 23%; p=0.02) and less urgent need of endovascular repair (0% vs 15.8%; p=0.013) without any impact on the need for transfusion. However, the incidence of atrial fibrillation was significantly higher (17.4% vs 9.4%; p=0.036). There was no significant difference between the two groups for the incidence of haemodynamic and neurological complications, high-degree atrioventricular block and in-hospital mortality.

Conclusion
According to our study, trans-carotid TAVI under local anesthesia can be feasible and safe, especially in more friable patients at higher risk. It was associated with lower incidence of vascular complications but a higher incidence of atrial fibrillation, without impact on in-hospital mortality. Randomized controlled trials are needed to establish a firm conclusion about this novel approach.

Funding Acknowledgement
Type of funding source: None