TCT-77 Transcarotid Versus Subclavian/Axillary Access for Transcatheter Aortic Valve Replacement: Real-World Comparative Outcomes Utilizing the TVT Registry

Background Transfemoral (TF) access is the preferred delivery method for transcatheter aortic valve replacement (TAVR). Despite advances in TAVR technology, alternative access remains necessary in contemporary practice. Transaxillary/subclavian (TAx) has gained favor as a delivery method, although transcarotid (TC) has become the preferred alternative access for selected sites. Comparison of these approaches has been limited. Methods The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies (TVT) Registry was queried for patients undergoing TC and TAx TAVR with the Sapien 3 (Edwards, Irvine, California) THV from June 2015 through February 2019. Baseline characteristics, unadjusted procedural outcomes, 30-day echocardiography outcomes, length of stay data, and unadjusted 30-day outcomes were evaluated. Results Among the patients undergoing TC and TAx TAVR, there were 2,739 cases. Of these, 17.01% were TC and 82.99% were TAx. Important statistically significant baseline characteristics included baseline STS score (TAx 7.3, TC 7.9; p = 0.008), prior CABG (TAx 23.2%, TC 30.7%; p = 0.0006), prior PCI (TAx 39.8%, TC 45.1%; p = 0.04), and peripheral arterial disease (TAx 65.9%, TC 73.9%; p = 0.0007). Important statistically significant differences in outcome included total procedure time (TAx 131.9 min, TC 122.4 min; p \u3c 0.0001), fluoroscopy time (TAx 21.5 min, TC 17.7 min; p \u3c 0.0001), contrast volume (TAx 97.3 ml, TC 82.7 ml; p \u3c 0.0001) and ICU length of stay (TAx 25.0 h, TC 24.3 h; p = 0.01). The 30-day outcomes had very few statistical differences including mean ejection fraction (TAx 55.6%, TC 57.2%; p = 0.02), and 30-day Kansas City Cardiomyopathy Questionnaire overall summary score (TAx 70.7, TC 67.8; p = 0.03). Stroke rates approached significance (TAx 6.4%, TC 4.2%; p = 0.07), and mortality was comparable (TAx 5%, TC 4.5%; p = 0.68). Conclusion Although TAx delivery has become a dominant alternative access for TAVR, TC offers many benefits as an alternative delivery route. Shorter operative and fluoroscopy times, shorter length of stay, lower contrast volume, and avoiding left internal mammary artery injury or occlusion are clear advantages. Concerns of elevated stroke rates in TC access appear to be unfounded based on these preliminary data. When femoral access is precluded, TC should be considered a viable access strategy compared with TAx access