Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA.
JACC Cardiovasc Interv. 2022 May 9;15(9):965-975. doi: 10.1016/j.jcin.2022.03.014.
The aim of this study was to compare transcaval and transaxillary artery access for transcatheter aortic valve replacement (TAVR) at experienced medical centers in contemporary practice.
There are no systematic comparisons of transcaval and transaxillary TAVR access routes.
Eight experienced centers contributed local data collected for the STS/ACC TVT Registry (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry) between 2017 and 2020. Outcomes after transcaval and axillary/subclavian (transaxillary) access were adjusted for baseline imbalances using doubly robust (inverse propensity weighting plus regression) estimation and compared.
Transcaval access was used in 238 procedures and transaxillary access in 106; for comparison, transfemoral access was used in 7,132 procedures. Risk profiles were higher among patients selected for nonfemoral access but similar among patients requiring transcaval and transaxillary access. Stroke and transient ischemic attack were 5-fold less common after transcaval than transaxillary access (2.5% vs 13.2%; OR: 0.20; 95% CI: 0.06-0.72; P = 0.014) compared with transfemoral access (1.7%). Major and life-threatening bleeding (Valve Academic Research Consortium 3 ≥ type 2) were comparable (10.0% vs 13.2%; OR: 0.66; 95% CI: 0.26-1.66; P = 0.38) compared with transfemoral access (3.5%), as was blood transfusion (19.3% vs 21.7%; OR: 1.07; 95% CI: 0.49-2.33; P = 0.87) compared with transfemoral access (7.1%). Vascular complications, intensive care unit and hospital length of stay, and survival were similar between transcaval and transaxillary access. More patients were discharged directly home and without stroke or transient ischemic attack after transcaval than transaxillary access (87.8% vs 62.3%; OR: 5.19; 95% CI: 2.45-11.0; P < 0.001) compared with transfemoral access (90.3%).
Patients undergoing transcaval TAVR had lower rates of stroke and similar bleeding compared with transaxillary access in a contemporary experience from 8 US centers. Both approaches had more complications than transfemoral access. Transcaval TAVR access may offer an attractive option.
本研究旨在比较经验丰富的医疗中心在当代实践中经腔静脉和经腋动脉入路行经导管主动脉瓣置换术（TAVR）的情况。
尚无经腔静脉和经腋动脉 TAVR 入路的系统比较。
8 个经验丰富的中心提供了 2017 年至 2020 年期间 STS/ACC TVT 登记处（胸外科医师学会/美国心脏病学会经导管瓣膜治疗登记处）收集的当地数据。使用双重稳健（逆倾向评分加权加回归）估计调整经腔静脉和腋动脉/锁骨下动脉（经腋动脉）入路后的结局，并进行比较。
238 例采用经腔静脉入路，106 例采用经腋动脉入路；相比之下，7132 例采用经股动脉入路。选择非股动脉入路的患者风险状况较高，但需要经腔静脉和经腋动脉入路的患者风险状况相似。与经股动脉入路（1.7%）相比，经腔静脉入路后发生卒中或短暂性脑缺血发作的几率低 5 倍（2.5% vs 13.2%；OR：0.20；95%CI：0.06-0.72；P=0.014）。与经股动脉入路（3.5%）相比，主要和危及生命的出血（瓣膜学术研究联盟 3 级≥2 型）相似（10.0% vs 13.2%；OR：0.66；95%CI：0.26-1.66；P=0.38），与经股动脉入路（7.1%）相比，输血也相似（19.3% vs 21.7%；OR：1.07；95%CI：0.49-2.33；P=0.87）。与经股动脉入路（7.1%）相比，血管并发症、重症监护病房和住院时间以及存活率在经腔静脉和经腋动脉入路之间相似。与经股动脉入路（90.3%）相比，经腔静脉入路的患者出院时直接回家且无卒中或短暂性脑缺血发作的比例更高（87.8% vs 62.3%；OR：5.19；95%CI：2.45-11.0；P<0.001）。
在 8 个美国中心的当代经验中，与经腋动脉入路相比，经腔静脉 TAVR 患者的卒中发生率较低，出血情况相似。与经股动脉入路相比，两种方法的并发症都更多。经腔静脉 TAVR 入路可能是一种有吸引力的选择。
