Femoral Versus Nonfemoral Peripheral Access for Transcatheter Aortic Valve Replacement

Sylvain Beurtheret (1) , Nicole Karam (2) , Noémie Resseguier (3) , Remi Houel (1) , Thomas Modine (4) , Thierry Folliguet (5) , Chekrallah Chamandi (2) , Olivier Com (1) , Richard Gelisse (1) , Jacques Bille (1) , Patrick Joly (1) , Nicolas Barra (1) , Alain Tavildari (1) , Philippe Commeau , Sebastien Armero , Mathieu Pankert , Michel Pansieri , Sabrina Siame (1) , René Koning (6) , Marc Laskar , Yvan Le Dolley (1) , Arnaud Maudiere (1) , Bertrand Villette (1) , Patrick Khanoyan (1) , Julien Seitz (1) , Didier Blanchard (2) , Christian Spaulding (2) , Thierry Lefevre , Eric van Belle (7) , Martine Gilard (8) , Hélène Eltchaninoff (9, 10) , Bernard Iung (11) , Jean Philippe Verhoye (12, 13) , Ramzi Abi-Akar (14) , Paul Achouh (15) , Thomas Cuisset (3) , Pascal Leprince (16) , Eloi Marijon (2) , Hervé Le Breton (13) , Antoine Lafont (14, 2)

1 Hôpital Saint-Joseph [Marseille]
2 PARCC - UMR-S U970 - Paris-Centre de Recherche Cardiovasculaire
3 TIMONE - Hôpital de la Timone [CHU - APHM]
4 CHRU Lille - Centre Hospitalier Régional Universitaire [CHU Lille]
5 CHRU Nancy - Centre Hospitalier Régional Universitaire de Nancy
6 Clinique Saint-Hilaire [Rouen]
7 RNMCD - Récepteurs nucléaires, maladies cardiovasculaires et diabète - U 1011
8 UBO UFR MSS - Université de Bretagne Occidentale - UFR Médecine et Sciences de la Santé
9 Service de Cardiologie [CHU Rouen]
10 Pharmacologie des Dysfonctionnements Endotheliaux et Myocardiques
11 CIC - CHU Bichat
12 Centre Hospitalier Universitaire de Rennes [CHU Rennes] = Rennes University Hospital [Ponchaillou]
13 LTSI - Laboratoire Traitement du Signal et de l'Image
14 HEGP - Hôpital Européen Georges Pompidou [APHP]
15 Service de chirurgie cardiaque et vasculaire [CHU HEGP]
16 CHU Pitié-Salpêtrière [AP-HP]

BACKGROUND: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.OBJECTIVES:This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR.METHODS: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 centers were performed. RESULTS: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 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 centers.CONCLUSIONS: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. n-FP TAVR may be favored over surgery in patients who are deemed ineligible for femoral TAVR and may be a safe alternative when femoral access risk is considered too high.

Mots clés: access site; outcome; TAVR

Domaines: Cardiologie et système cardiovasculaire; Chirurgie

Sylvain Beurtheret, Nicole Karam, Noémie Resseguier, Remi Houel, Thomas Modine, et al.. Femoral Versus Nonfemoral Peripheral Access for Transcatheter Aortic Valve Replacement. Journal of the American College of Cardiology, 2019, 74 (22), pp.2728-2739. ⟨10.1016/j.jacc.2019.09.054⟩. ⟨hal-02393875⟩