05 Dec 2019

TAVI Iliac / Femoral / Popliteal

Femoral versus nonfemoral peripheral access for transcatheter aortic valve replacement

Selected in Journal of the American College of Cardiology by S. Brugaletta

Using the data from the national prospective French registry (FRANCE TAVI), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a nonfemoral peripheral access.

References

Authors

S Beurtheret, N Karam, N Resseguier, R Houel, T Modine, T Folliguet, C Chamandi, O Com, R Gelisse, J Bille, P Joly, N Barra, A Tavildari, P Commeau, S Armero, M Pankert, M Pansieri, S Siame, R Koning, M Laskar, Y Le Dolley, A Maudiere, B Villette, P Khanoyan, J Seitz, D Blanchard, C Spaulding, T Lefevre, E Van Belle, M Gilard, H Eltchaninoff, B Iung, JP Verhoye, R Abi-Akar, P Achouh,

Reference

J Am Coll Cardiol. 74:2728–39

Published

December 2019

Link

Read the abstract

Reviewer

Salvatore Brugaletta

@sbrugaletta

Interventional cardiologist / Cardiologist

Barcelona, Spain

Latest contributions

Optical coherence tomography- vs angiography-guided coronary stent implantation in calcified lesions: the ILUMIEN IV trial Percutaneous coronary treatment with Bioadaptor implant vs drug-eluting stent : 2-year outcomes from BIOADAPTOR RCT Coronary revascularisation deferral based on quantitative flow ratio or fractional flow reserve: a post-hoc analysis of the FAVOR III Europe trial

My Comment

Why this study – the rationale/objective?

Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Guidelines recommend reconsidering surgery when this access is not feasible. However, alternative peripheral accesses exist, although they have not been accurately compared with femoral access. This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR.

How was it executed – the methodology?

Using the data from the national prospective French registry (FRANCE TAVI [French Transcatheter Aortic Valve Implantation]), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a n-FP access, using a pre-specified propensity score-based matching between groups.

Subanalysis during 2 study periods (2013 to 2015 and 2016 to 2017) and among low/intermediate-low and intermediate-high/high volume centres were performed.

What is the main result?

Among 21,611 patients, 19,995 (92.5%) underwent femoral TAVR and 1,616 (7.5%) underwent n-FP TAVR (transcarotid, n = 914 or trans-subclavian, n = 702). Patients in the n-FP access group had more severe disease (mean logistic EuroSCORE 19.95 vs. 16.95; p < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease, and renal failure.

After propensity score matching, there was no difference in the rate of post-procedural death and complications according to access site, except for a 2-fold lower rate of major vascular complications (odds ratio: 0.45; 95% confidence interval: 0.21 to 0.93; p = 0.032) and unplanned vascular repairs (odds ratio: 0.41; 95% confidence interval: 0.29 to 0.59; p < 0.001) in those who underwent n-FP access.

The comparison of outcomes provided similar results during the second study period and in intermediate-high/high volume centres.

Critical reading and relevance for clinical practice

This study, based on the TAVI French registry, shows that n-FP TAVR is associated with similar outcomes compared with femoral peripheral TAVR, except for a 2-fold lower rate of major vascular complications and unplanned vascular repairs. This is the first time that no-femoral access is found to be associated with lower rate of access complications and this is the reason why the study is worth.

So far we used to read that any access different from femoral was associated with higher rate of vascular access complications. This may mean that during the years interventional cardiologists and surgeons became more confident with non-femoral access resulting in better management.

It is still to investigate which is the best non-femoral access. which no femoral access do you use in your TAVR patients not suitable for femoral access?