Paradigm shifts in alternative access for transcatheter aortic valve replacement: An update.

Central MessageAn in-depth understanding of the risks and benefits of alternatives to transfemoral access is crucial for optimizing the outcomes associated with transcatheter aortic valve replacement.See Commentaries on pages 1371 and 1372. An in-depth understanding of the risks and benefits of alternatives to transfemoral access is crucial for optimizing the outcomes associated with transcatheter aortic valve replacement. See Commentaries on pages 1371 and 1372. Over the last decade, transcatheter aortic valve replacement (TAVR) has evolved from a procedure reserved for high-to-prohibitive surgical risk patients,1Leon M.B. Smith C.R. Mack M. Miller D.C. Moses J.W. Svensson L.G. et al.Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5539) Google Scholar, 2Popma J.J. Adams D.H. Reardon M.J. Yakubov S.J. Kleiman N.S. Heimansohn D. et al.Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery.J Am Coll Cardiol. 2014; 63: 1972-1981Crossref PubMed Scopus (804) Google Scholar, 3Smith C.R. Leon M.B. Mack M.J. Miller D.C. Moses J.W. Svensson L.G. et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4874) Google Scholar to an established therapeutic alternative to surgical aortic valve replacement (SAVR) in the low-to-intermediate risk population.4Mack M.J. Leon M.B. Thourani V.H. Makkar R. Kodali S.K. Russo M. et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Crossref PubMed Scopus (2557) Google Scholar, 5Popma J.J. Deeb G.M. Yakubov S.J. Mumtaz M. Gada H. O'Hair D. et al.Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380: 1706-1715Crossref PubMed Scopus (1958) Google Scholar, 6Reardon M.J. Van Mieghem N.M. Popma J.J. Kleiman N.S. Sondergaard L. Mumtaz M. et al.Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2017; 376: 1321-1331Crossref PubMed Scopus (1848) Google Scholar, 7Leon M.B. Smith C.R. Mack M.J. Makkar R.R. Svensson L.G. Kodali S.K. et al.Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620Crossref PubMed Scopus (3345) Google Scholar The femoral artery is the first-choice approach whenever possible,8Cerrato E. Nombela-Franco L. Nazif T.M. Eltchaninoff H. Sondergaard L. Ribeiro H.B. et al.Evaluation of current practices in transcatheter aortic valve implantation: the WRITTEN (WoRldwIde TAVI ExperieNce) survey.Int J Cardiol. 2017; 228: 640-647Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar as this was the predominant access site used in all of the randomized trials comparing TAVR with SAVR. Recent registries have shown a significant decrease in the proportion of patients treated through a non-transfemoral (TF) access, from nearly 20% to 5%,9Siontis G.C.M. Overtchouk P. Cahill T.J. Modine T. Prendergast B. Praz F. et al.Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis.Eur Heart J. 2019; 40: 3143-3153Crossref PubMed Scopus (222) Google Scholar, 10Carroll J.D. Mack M.J. Vemulapalli S. Herrmann H.C. Gleason T.G. Hanzel G. et al.STS-ACC TVT registry of transcatheter aortic valve replacement.J Am Coll Cardiol. 2020; 76: 2492-2516Crossref PubMed Scopus (329) Google Scholar, 11Auffret V. Lefevre T. Van Belle E. Eltchaninoff H. Iung B. Koning R. et al.Temporal trends in transcatheter aortic valve replacement in France: FRANCE 2 to FRANCE TAVI.J Am Coll Cardiol. 2017; 70: 42-55Crossref PubMed Scopus (244) Google Scholar, 12Grover F.L. Vemulapalli S. Carroll J.D. Edwards F.H. Mack M.J. Thourani V.H. et al.2016 annual report of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.J Am Coll Cardiol. 2017; 69: 1215-1230Crossref PubMed Scopus (382) Google Scholar as a consequence of the iterative technological improvements in transcatheter heart valves (THV) and delivery system profiles. Nonetheless, considering the rapid increase in the number of TAVR procedures performed worldwide, it is reasonable to assume that some proportion of these patients will not be candidates for TF-TAVR.10Carroll J.D. Mack M.J. Vemulapalli S. Herrmann H.C. Gleason T.G. Hanzel G. et al.STS-ACC TVT registry of transcatheter aortic valve replacement.J Am Coll Cardiol. 2020; 76: 2492-2516Crossref PubMed Scopus (329) Google Scholar In these cases, attempting a TF-TAVR despite an unfavorable ileofemoral anatomy may be associated with greater rates of vascular injury and mortality.13Hayashida K. Lefevre T. Chevalier B. Hovasse T. Romano M. Garot P. et al.Transfemoral aortic valve implantation new criteria to predict vascular complications.JACC Cardiovasc Interv. 2011; 4: 851-858Crossref PubMed Scopus (424) Google Scholar,14Arnold S.V. Manandhar P. Vemulapalli S. Kosinski A. Desai N.D. Bavaria J.E. et al.Impact of short-term complications of TAVR on longer-term outcomes: results from the STS/ACC Transcatheter Valve Therapy Registry.Eur Heart J Qual Care Clin Outcomes. 2021; 7: 208-213Crossref PubMed Scopus (16) Google Scholar Furthermore, as TAVR expands toward a lower-risk population, similar outcomes as those achieved by TF access are mandatory to rival the excellent results associated with SAVR in this subset of patients. Several transthoracic (transapical [TA]/transaortic [TAo]) and peripheral (transcarotid [TC], transsubclavian [TS], transcaval [TCv]) vascular access routes were developed as alternatives in the event that TF access was unsuitable. A careful evaluation of patients' comorbidities and vascular anatomy is necessary to choose the best alternative access, as each technique has its advantages and disadvantages (Table 1).Table 1Relative advantages and disadvantages associated with the different TAVR approachesAdvantagesDisadvantagesTransapical•Easy aortic valve crossing•Excellent THV maneuverability•Not limited by peripheral vascular anatomy and size•General anesthesia and mechanical ventilation•Mini-thoracotomy•Irreversible damage to apical myocardium possibly limiting LVEF improvement post-TAVR•Longer in-hospital stay•Relative contraindications:•Chronic respiratory insufficiency•Severe left ventricular dysfunction•Left ventricular clotTransaortic•Excellent THV maneuverability•No guidewire manipulation of aortic arch and supra-aortic vessels•Rapid conversion to full sternotomy if necessary•Not limited by peripheral vascular anatomy and size•General anesthesia and mechanical ventilation•Partial sternotomy (unless suprasternal access)•Longer in-hospital stay•Relative contraindications:•Chronic respiratory insufficiency•Previous sternotomy•Porcelain aorta•Short ascending aorta (<6 cm from the puncture site to the aortic annulus)•Previous chest radiationTranscarotid•Possibility of local anesthesia and conscious sedation•Superficial and accessible location of the common carotid artery•Common carotid is usually spared of atherosclerotic disease compared with femoral arteries•Easy alignment with the aortic annulus•No guidewire manipulation of aortic arch•Surgical cut-down is necessary•Relative contraindications:•Congenital variants of the aortic arch•Common carotid artery minimal lumen diameter <6 mm•Contralateral significant (≥50%) internal or common carotid artery stenosis or occlusionTranssubclavianPossibility of local anesthesia and conscious sedation.•Proximity to the aortic annulus•Subclavian artery is usually spared of atherosclerotic disease compared with femoral arteries•Alignment with the aortic annulus more difficult•Deep location, surgical access challenging in patients with obesity•Proximity of the brachial plexus•Bailout technically difficult if vascular complications•Relative contraindications:•Subclavian artery minimal lumen diameter <6 mm•Vascular anatomy: tortuosity, stenosis, angulation•Patent ipsilateral internal mammary artery graft•Patients with obesity•Steep subclavian to aortic arch angulationTranscaval•Fully percutaneous venous access•Possibility of local anesthesia and conscious•Sedation•Extensive preoperative planning from the multislice CT•Added cost of closure devices•Presence of intestine within the access pathway•Relative contraindications:•Calcification/atheroma/aneurysm/chronic dissection of descending aorta•Increased distance between descending aorta and inferior vena cavaTHV, Transcatheter heart valve; LVEF, left ventricular ejection fraction; TAVR, transcatheter aortic valve replacement; CT, computed tomography. Open table in a new tab THV, Transcatheter heart valve; LVEF, left ventricular ejection fraction; TAVR, transcatheter aortic valve replacement; CT, computed tomography. In the early years of TAVR, TF access was associated with improved clinical outcomes compared with other more-invasive vascular approaches.15Blackstone E.H. Suri R.M. Rajeswaran J. Babaliaros V. Douglas P.S. Fearon W.F. et al.Propensity-matched comparisons of clinical outcomes after transapical or transfemoral transcatheter aortic valve replacement: a placement of aortic transcatheter valves (PARTNER)-I trial substudy.Circulation. 2015; 131: 1989-2000Crossref PubMed Scopus (228) Google Scholar However, in an intermediate-risk population treated with second-generation THVs through a TF approach, the risks of major and/or life-threatening bleeding and major vascular complications were reported to be as high as 12% and 8%, respectively, raising the question as to whether patients with a nonoptimal TF access should continue to be treated using this approach.6Reardon M.J. Van Mieghem N.M. Popma J.J. Kleiman N.S. Sondergaard L. Mumtaz M. et al.Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2017; 376: 1321-1331Crossref PubMed Scopus (1848) Google Scholar,7Leon M.B. Smith C.R. Mack M.J. Makkar R.R. Svensson L.G. Kodali S.K. et al.Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620Crossref PubMed Scopus (3345) Google Scholar There is increasing evidence suggesting that, to reduce access-related vascular and bleeding complications, as well as the excess early and late mortality associated with these complications, a safe alternative access site should be considered based on the individual patient's anatomical characteristics.14Arnold S.V. Manandhar P. Vemulapalli S. Kosinski A. Desai N.D. Bavaria J.E. et al.Impact of short-term complications of TAVR on longer-term outcomes: results from the STS/ACC Transcatheter Valve Therapy Registry.Eur Heart J Qual Care Clin Outcomes. 2021; 7: 208-213Crossref PubMed Scopus (16) Google Scholar This article aims to provide a brief and up-to-date comparative review, focusing on the strengths and weaknesses of the currently available alternative-access TAVR approaches. During the early experience with TAVR procedures, transthoracic approaches were the preferred alternative routes, as the high-profile introducer sheaths precluded the use of safe alternative peripheral arterial access. The TA pathway, first performed by Ye and colleagues in 2005,16Ye J. Cheung A. Lichtenstein S.V. Carere R.G. Thompson C.R. Pasupati S. et al.Transapical aortic valve implantation in humans.J Thorac Cardiovasc Surg. 2006; 131: 1194-1196Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar was the first alternative access attempted for TAVR. Despite a need for an anterolateral mini-thoracotomy, general anesthesia, and the insertion of the THV delivery system though the left ventricular apex, TA access was the only anterograde approach that allowed for straightforward guidewire crossing of the aortic valve and excellent THV maneuverability.17Nakatsuka D. Tabata M. Transapical approach for transcatheter aortic valve implantation.Ann Cardiothorac Surg. 2017; 6: 553-554Crossref PubMed Scopus (10) Google Scholar Nevertheless, the TA approach has been associated with myocardial damage, and a smaller extent of improvement in left ventricular function after TAVR,18Rodes-Cabau J. Gutierrez M. Bagur R. De Larochelliere R. Doyle D. Cote M. et al.Incidence, predictive factors, and prognostic value of myocardial injury following uncomplicated transcatheter aortic valve implantation.J Am Coll Cardiol. 2011; 57: 1988-1999Crossref PubMed Scopus (167) Google Scholar,19Elmariah S. Fearon W.F. Inglessis I. Vlahakes G.J. Lindman B.R. Alu M.C. et al.Transapical transcatheter aortic valve replacement is associated with increased cardiac mortality in patients with left ventricular dysfunction: insights from the PARTNER I Trial.JACC Cardiovasc Interv. 2017; 10: 2414-2422Crossref PubMed Scopus (42) Google Scholar as well as various other important procedure-related complications, such as tamponade and, albeit rare, injury to the mitral subvalvular apparatus. Intractable bleeding at the left ventricular apex is also rare but may be a potentially catastrophic complication that often requires cardiopulmonary bypass. Access involving the ascending aorta was developed as a means of countering the potential complications related to left ventricular apical access in elderly and frail patients, and the TAo route was first described in 2010.20Latsios G. Gerckens U. Grube E. Transaortic transcatheter aortic valve implantation: a novel approach for the truly “no-access option” patients.Catheter Cardiovasc Interv. 2010; 75: 1129-1136PubMed Google Scholar A partial upper sternotomy is performed, extended down to the second or third right intercostal space, although sternal-sparing approaches have been described, such as an incision through the suprasternal notch. General anesthesia is required. Previous sternotomy, especially with patent coronary bypass grafts, and a heavily calcified ascending aorta are generally prohibitive. Studies reporting the outcomes associated with TA/TAo TAVR are listed in Table 2. Data from large registries of high-risk patients showed 30-day and 1-year mortality rates ranging from 9% to 14% and 25% to 32% after TA-TAVR21Thomas M. Schymik G. Walther T. Himbert D. Lefevre T. Treede H. et al.Thirty-day results of the SAPIEN aortic Bioprosthesis European Outcome (SOURCE) Registry: a European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve.Circulation. 2010; 122: 62-69Crossref PubMed Scopus (757) Google Scholar, 22Schymik G. Lefevre T. Bartorelli A.L. Rubino P. Treede H. Walther T. et al.European experience with the second-generation Edwards SAPIEN XT transcatheter heart valve in patients with severe aortic stenosis: 1-year outcomes from the SOURCE XT Registry.JACC Cardiovasc Interv. 2015; 8: 657-669Crossref PubMed Scopus (91) Google Scholar, 23Gilard M. Eltchaninoff H. Iung B. Donzeau-Gouge P. Chevreul K. Fajadet J. et al.Registry of transcatheter aortic-valve implantation in high-risk patients.N Engl J Med. 2012; 366: 1705-1715Crossref PubMed Scopus (1050) Google Scholar, 24Thourani V.H. Jensen H.A. Babaliaros V. Suri R. Vemulapalli S. Dai D. et al.Transapical and transaortic transcatheter aortic valve replacement in the United States.Ann Thorac Surg. 2015; 100 (discussion 1726-7): 1718-1726Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 25Mack M.J. Brennan J.M. Brindis R. Carroll J. Edwards F. Grover F. et al.Outcomes following transcatheter aortic valve replacement in the United States.JAMA. 2013; 310: 2069-2077Crossref PubMed Scopus (394) Google Scholar, E1Di Mario C. Eltchaninoff H. Moat N. Goicolea J. Ussia G.P. Kala P. et al.The 2011-12 pilot European Sentinel Registry of Transcatheter Aortic Valve Implantation: in-hospital results in 4,571 patients.EuroIntervention. 2013; 8: 1362-1371Crossref PubMed Scopus (167) Google Scholar, E2Frohlich G.M. Baxter P.D. Malkin C.J. Scott D.J. Moat N.E. Hildick-Smith D. et al.Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry).Am J Cardiol. 2015; 116: 1555-1559Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, E3Wendler O. Walther T. Schroefel H. Lange R. Treede H. Fusari M. et al.Transapical aortic valve implantation: mid-term outcome from the SOURCE registry.Eur J Cardiothorac Surg. 2013; 43 (discussion 511-2): 505-511Crossref PubMed Scopus (37) Google Scholar and 6% to 10% and 19% to 30% after TAo-TAVR,24Thourani V.H. Jensen H.A. Babaliaros V. Suri R. Vemulapalli S. Dai D. et al.Transapical and transaortic transcatheter aortic valve replacement in the United States.Ann Thorac Surg. 2015; 100 (discussion 1726-7): 1718-1726Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar,E4Cocchieri R. Petzina R. Romano M. Jagielak D. Bonaros N. Aiello M. et al.Outcomes after transaortic transcatheter aortic valve implantation: long-term findings from the European ROUTE†.Eur J Cardiothorac Surg. 2019; 55: 737-743Crossref PubMed Scopus (13) Google Scholar,E5Bapat V. Frank D. Cocchieri R. Jagielak D. Bonaros N. Aiello M. et al.Transcatheter aortic valve replacement using transaortic access: experience from the multicenter, multinational, prospective ROUTE Registry.JACC Cardiovasc Interv. 2016; 9: 1815-1822Crossref PubMed Scopus (35) Google Scholar respectively. Major vascular complications, major bleeding events, and stroke were similar between TA and TAo approaches.24Thourani V.H. Jensen H.A. Babaliaros V. Suri R. Vemulapalli S. Dai D. et al.Transapical and transaortic transcatheter aortic valve replacement in the United States.Ann Thorac Surg. 2015; 100 (discussion 1726-7): 1718-1726Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar,E2Frohlich G.M. Baxter P.D. Malkin C.J. Scott D.J. Moat N.E. Hildick-Smith D. et al.Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry).Am J Cardiol. 2015; 116: 1555-1559Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar,E6KE O.S. Hurley E.T. Segurado R. Sugrue D. Hurley J.P. Transaortic TAVI is a valid alternative to transapical approach.J Card Surg. 2015; 30: 381-390Crossref PubMed Scopus (16) Google Scholar Thourani and colleagues24Thourani V.H. Jensen H.A. Babaliaros V. Suri R. Vemulapalli S. Dai D. et al.Transapical and transaortic transcatheter aortic valve replacement in the United States.Ann Thorac Surg. 2015; 100 (discussion 1726-7): 1718-1726Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar reported a greater rate of 30-day and 1-year unadjusted mortality in the TAo access group, but these differences were no longer statistically significant after a risk-adjusted analysis.Table 2Summary of the main transthoracic access studies and studies comparing transthoracic versus transfemoral TAVRAuthorsComparative groupsStudy typeStudy period, yAge, yRisk stratificationPeriprocedural outcomesFollow-up outcomesSTS PROMLog ESCVAMajor VCMajor/LT bleedingAKIIn-hospital stay, dIn-hospital death30-d mortality/CV mortality1-y mortality/CV mortalityTransthoracic registriesWendler et al. SOURCE REGISTRYE3Wendler O. Walther T. Schroefel H. Lange R. Treede H. Fusari M. et al.Transapical aortic valve implantation: mid-term outcome from the SOURCE registry.Eur J Cardiothorac Surg. 2013; 43 (discussion 511-2): 505-511Crossref PubMed Scopus (37) Google ScholarTransapical (n = 1387)Prospective registry2007-200980.6 ± 7.1–27.6 ± 16.12.51.5Major: 3.96.7∗Renal failure requiring dialysis.––11.226.2 Bapat et al, Cocchieri et al, ROUTE REGISTRYE5Bapat V. Frank D. Cocchieri R. Jagielak D. Bonaros N. Aiello M. et al.Transcatheter aortic valve replacement using transaortic access: experience from the multicenter, multinational, prospective ROUTE Registry.JACC Cardiovasc Interv. 2016; 9: 1815-1822Crossref PubMed Scopus (35) Google ScholarTransaortic (n = 301)Prospective registry2013-201581.7 ± 5.99.0 ± 7.6–1.43.4LT: 3.49.5†Acute kidney injury (stage 2 or 3).9.9 ± 8.5–6.1/4.419.1 Thourani et al. TVT REGISTRY24Thourani V.H. Jensen H.A. Babaliaros V. Suri R. Vemulapalli S. Dai D. et al.Transapical and transaortic transcatheter aortic valve replacement in the United States.Ann Thorac Surg. 2015; 100 (discussion 1726-7): 1718-1726Abstract Full Text Full Text PDF PubMed Scopus (56) Google ScholarTransapical (n = 4085)Prospective registry. Retrospective analysis2011-201482.6 ± 6.8‡P < .05.7.4 (5-11)–2.10.3–38.8§Acute kidney injury (stage 1-3).8.5 ± 6.6‡P < .05.6.88.8‡P < .05.25.6‡P < .05. Transaortic (n = 868)83.6 ± 6.8‡P < .05.8.8 (6-13)–2.50.3–39.6‡P < .05.8.9 ± 6.4‡P < .05.8.110.3‡P < .05.30.3‡P < .05.Transfemoral vs transapical studiesBlackman et al, UK TAVI REGISTRYE9Blackman D.J. Baxter P.D. Gale C.P. Moat N.E. Maccarthy P.A. Hildick-Smith D. et al.Do outcomes from transcatheter aortic valve implantation vary according to access route and valve type? The UK TAVI Registry.J Interv Cardiol. 2014; 27: 86-95Crossref PubMed Scopus (71) Google ScholarTransfemoral (n = 387)Prospective registry. Retrospective analysis2007-201082.2 ± 7.4–17.7 ± 11.1‡P < .05.3.39.0‡P < .05.18.6‡P < .05.‖Blood loss requiring transfusion.3.4‡P < .05.∗Renal failure requiring dialysis.––4.4‡P < .05.18.1‡P < .05. Transapical (n = 408)81.8 ± 6.9–22.5 ± 12.9‡P < .05.3.42.2‡P < .05.28.7‡P < .05.‖Blood loss requiring transfusion.8.6‡P < .05.∗Renal failure requiring dialysis.––11.2‡P < .05.28.7‡P < .05. Schymik et al, SOURCE XT REGISTRY22Schymik G. Lefevre T. Bartorelli A.L. Rubino P. Treede H. Walther T. et al.European experience with the second-generation Edwards SAPIEN XT transcatheter heart valve in patients with severe aortic stenosis: 1-year outcomes from the SOURCE XT Registry.JACC Cardiovasc Interv. 2015; 8: 657-669Crossref PubMed Scopus (91) Google ScholarTransfemoral (n = 1685)Prospective registry. Retrospective analysis2010 - 201182.0 ± 6.5‡P < .05.–19.8 ± 11.6‡P < .05.3.47.9‡P < .05.10.9‡P < .05.11.9‡P < .05.§Acute kidney injury (stage 1-3).–1.54.2‡P < .05./1.7‡P < .05.15.0‡P < .05./6.7‡P < .05. Transapical (n = 894)80.1 ± 6.4‡P < .05.–21.9 ± 13.7‡P < .05.4.23.5‡P < .05.20.9‡P < .05.28.1‡P < .05.§Acute kidney injury (stage 1-3).–2.510.0‡P < .05./5.7‡P < .05.27.1‡P < .05./14.7‡P < .05. Blackstone et al PARTNER 1 TA15Blackstone E.H. Suri R.M. Rajeswaran J. Babaliaros V. Douglas P.S. Fearon W.F. et al.Propensity-matched comparisons of clinical outcomes after transapical or transfemoral transcatheter aortic valve replacement: a placement of aortic transcatheter valves (PARTNER)-I trial substudy.Circulation. 2015; 131: 1989-2000Crossref PubMed Scopus (228) Google ScholarTransfemoral (n = 501)Prospective. Propensity score matched2007-201285 ± 6.8––2.86.0Major: 4.8–5 (3-8)‡P < .05.2.8‡P < .05.3.4‡P < .05.– Transapical (n = 501)85 ± 6.3––3.23.8Major: 7.2–8 (5-15)‡P < .05.7.4‡P < .05.9.0‡P < .05.– Doshi et alE12Doshi R. Shah P. Meraj P.M. In-hospital outcomes comparison of transfemoral vs transapical transcatheter aortic valve replacement in propensity-matched cohorts with severe aortic stenosis.Clin Cardiol. 2018; 41: 326-332Crossref PubMed Scopus (19) Google ScholarTransfemoral (n = 3954)Retrospective Propensity score matched (3:1)2012-201481.1 ± 8.5‡P < .05.––2.74.3‡P < .05.31.1‡P < .05.‖Blood loss requiring transfusion.17.1‡P < .05.7.7 ± 7.3‡P < .05.4.0‡P < .05.–– Transapical (n = 1318)81.0 ± 8.1‡P < .05.––2.91.9‡P < .05.36.4‡P < .05.‖Blood loss requiring transfusion.23.9‡P < .05.9.7 ± 7.8‡P < .05.5.4‡P < .05.–– Schymik et alE7Schymik G. Wurth A. Bramlage P. Herbinger T. Heimeshoff M. Pilz L. et al.Long-term results of transapical versus transfemoral TAVI in a real world population of 1000 patients with severe symptomatic aortic stenosis.Circ Cardiovasc Interv. 2015; 8: e000761Crossref PubMed Scopus (70) Google ScholarTransfemoral (n = 354)Retrospective Propensity score matched2008-201281.7 ± 5.0–23.5 ± 16.32.315.8‡P < .05.13.620.9‡P < .05.§Acute kidney injury (stage 1-3).––8.5NS Transapical (n = 354)81.8 ± 5.9–23.0 ± 15.62.02.5‡P < .05.10.135.6‡P < .05.§Acute kidney injury (stage 1-3).––5.9NSTransfemoral vs transaortic studiesO'Hair et al, CoreValve US High Risk and Extreme Risk Pivotal TrialsE13O'Hair D.P. Bajwa T.K. Popma J.J. Watson D.R. Yakubov S.J. Adams D.H. et al.Direct aortic access for transcatheter aortic valve replacement using a self-expanding device.Ann Thorac Surg. 2018; 105: 484-490Abstract Full Text Full Text PDF PubMed Scopus (12) Google ScholarTransfemoral (n = 394)Retrospective Propensity score matched2011-201283.2 ± 7.69.7 ± 5.0–2.6‡P < .05.9.4‡P < .05.35.4‡P < .05.10.0‡P < .05.§Acute kidney injury (stage 1-3).8.4 ± 8.7‡P < .05.–4.1‡P < .05./4.1‡P < .05.23.2/17.3‡P < .05. Transaortic (n = 394)82.8 ± 7.69.7 ± 4.8–5.7‡P < .05.4.1‡P < .05.66.7‡P < .05.19.7‡P < .05.§Acute kidney injury (stage 1-3).10.8 ± 8.2‡P < .05.–10.9‡P < .05./10.7‡P < .05.28.1/22.2‡P < .05. Chollet et alE8Chollet T. Marcheix B. Boudou N. Elbaz M. Campelo-Parada F. Bataille V. et al.Propensity-matched comparison of clinical outcomes after transaortic versus transfemoral aortic valve replacement.EuroIntervention. 2018; 14: 750-757Crossref PubMed Scopus (12) Google ScholarTransfemoral (n = 124)Retrospective Propensity score matched2012-201583.9 ± 6.26.5 ± 3.6–4.02.42.4‡P < .05.1.7†Acute kidney injury (stage 2 or 3).6.4 ± 1.8‡P < .05.1.66.516.1 Transaortic (n = 124)84.1 ± 6.46.9 ± 3.6–2.44.89.7‡P < .05.3.7†Acute kidney injury (stage 2 or 3).9.1 ± 3.6‡P < .05.5.77.315.3Values are %, unless otherwise indicated. STS PROM, Society of Thoracic Surgeons predicted risk of mortality; Log ES, logistic EuroSCORE; CVA, cerebrovascular accident; VC, vascular complication; LT, life-threatening; AKI, acute kidney injury; CV, cardiovascular; NS, not significant.∗ Renal failure requiring dialysis.† Acute kidney injury (stage 2 or 3).‡ P < .05.§ Acute kidney injury (stage 1-3).‖ Blood loss requiring transfusion. Open table in a new tab Values are %, unless otherwise indicated. STS PROM, Society of Thoracic Surgeons predicted risk of mortality; Log ES, logistic EuroSCORE; CVA, cerebrovascular accident; VC, vascular complication; LT, life-threatening; AKI, acute kidney injury; CV, cardiovascular; NS, not significant. Meaningful comparisons between transthoracic and TF access are problematic, due to the routine use of TF as the first-line approach, with transthoracic access reserved for cases not amenable to nontransthoracic access, which are generally considered to be at a greater risk. Between-group differences could therefore be wrongly attributed to the type of TAVR access, rather than to the patient's preprocedural risk profile, with access usually emerging as an independent predictor of poor outcome. There are a few propensity-score matched studies that suggest that there is no inherent access-related detrimental effect among the transthoracic approaches.E7Schymik G. Wurth A. Bramlage P. Herbinger T. Heimeshoff M. Pilz L. et al.Long-term results of transapical versus transfemoral TAVI in a real world population of 1000 patients with severe symptomatic aortic stenosis.Circ Cardiovasc Interv. 2015; 8: e000761Crossref PubMed Scopus (70) Google Scholar, E8Chollet T. Marcheix B. Boudou N. Elbaz M. Campelo-Parada F. Bataille V. et al.Propensity-matched comparison of clinical outcomes after transaortic versus transfemoral aortic valve replacement.EuroIntervention. 2018; 14: 750-757Crossref PubMed Scopus (12) Google Scholar However, a majority of comparative studies, even after risk adjustment, report significantly greater rates of major adverse events such as postprocedural major/life-threatening bleeding, acute renal failure, and in-hospital mortality among patients undergoing transthoracic access.15Blackstone E.H. Suri R.M. Rajeswaran J. Babaliaros V. Douglas P.S. Fearon W.F. et al.Propensity-matched comparisons of clinical outcomes after transapical or transfemoral transcatheter aortic valve replacement: a placement of aortic transcatheter valves (PARTNER)-I trial substudy.Circulation. 2015; 131: 1989-2000Crossref PubMed Scopus (228) Google Scholar,E9Blackman D.J. Baxter P.D. Gale C.P. Moat N.E. Maccarthy P.A. Hildick-Smith D. et al.Do outcomes from transcatheter aortic valve implantation vary according to access route and valve type? The UK TAVI Registry.J Interv Cardiol. 2014; 27: 86-95Crossref PubMed Scopus (71) Google Scholar, E13O'Hair D.P. Bajwa T.K. Popma J.J. Watson D.R. Yakubov S.J. Adams D.H. et al.Direct aortic access for transcatheter aortic valve replacement using a self-expanding device.Ann Thorac Surg. 2018; 105: 484-490Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Late survival was also reduced when compared with TF-TAVR.23Gilard M. Eltchaninoff H. Iung B. Donzeau-Gouge P. Chevreul K. Fajadet J. et al.Registry of transcatheter aortic-valve implantation in high-risk patients.N Engl J Med. 2012; 366: 1705-1715Crossref PubMed Scopus (1050) Google Scholar,E2Frohlich G.M. Baxter P.D. Malkin C.J. Scott D.J. Moat N.E. Hildick-Smith D. et al.Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry).Am J Cardiol. 2015; 116: 1555-1559Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Stroke risk after the transthoracic approaches is low; the avoidance of retrograde guidewire crossing of the aortic arch, and catheter manipulation in the arch are possible reasons.E14Eggebrecht H. Schmermund A. Voigtlander T. Kahlert P. Erbel R. Mehta R.H. Risk of stroke after transcatheter aortic valve implantation (TAVI): a met