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Brachiocephalic Artery Access in TAVI: a Safe and Feasible Alternative for Retrograde Access
Tine E. Philipsen, Valérie M. Collas, Johan M. Bosmans, Marc J. Claeys, Inez E. Rodrigus.
UZA - Antwerp University Hospital, Edegem, Belgium.

Objective Transcatheter aortic valve implantation (TAVI) is an accepted treatment for selected high risk patients with severe aortic stenosis. Vascular access and access related complications remain a key point of concern. We report our initial experience with the brachiocephalic artery access, a new approach for retrograde TAVI. Methods The ideal patient-tailored access is decided based on the pre-procedural thoracic angio-CT scan. In patients with poor iliofemoral access (small vessels, severe atherosclerosis, previous vascular surgery or stenting) or with patent LIMA graft after previous CABG, the open brachiocephalic artery access is preferred. The approach can be either suprasternal or through upper ministernotomy. Results In 179 subsequent TAVI procedures (Medtronic CoreValve ®) performed by retrograde access in our center, the iliofemoral access was not deemed feasible in 31 patients (17,3%). As an alternative, we preferred the brachiocephalic artery in 15 patients. In 73%, the suprasternal approach provided excellent access. Patient baseline characteristics are given in table 1. The procedural success rate was 100 %, we saw no intraprocedural mortality, no conversion to open surgery was needed and all valves were well positioned. Mean length of hospital stay was 9 days (range 5-14). Early safety was excellent, no periprocedural myocardial infarction, stroke, transient ischemic attack, acute kidney injury, major vascular or major bleeding complications were seen. 2 patients needed a permanent pacemaker within 2 days post TAVI because of a new third-degree AV block. Echocardiography at discharge showed one mild to moderate paravalvular aortic valve insufficiency and overall low mean gradients over the valve (range 6 - 14mmHg (mean 9)). Conclusions TAVI implantation trough the brachiocephalic artery is safe and feasible. The surgical access is easily performed. The distance between the point of access and the aortic valve annulus is short, hereby improving catheter stability and accurate implantation. It therefore is a good option in patients without femoral access and might even be a good alternative for the transapical approach.

Table 1: baseline characteristics
male (%, N)80 % (12)
age (mean, y)79,1
BSA (mean, m2)1,81
log EuroScore (mean)27,32
STS score (mean)7,519
NYHA class 3-4 (%, N)93,3 % (14)
AVA (mean, cm2)0,61 (range 0,4 - 0,86)
peak gradient aortic valve (mean, mmHg)69,1 (range 39 - 106)
mean gradient aortic valve (mean, mmHg)45 (range 30 - 69)
peripheral arterial disease (%, N)93,3 % (14)
porcelain aorta (%, N)33,3 % (5)
previous vascular surgery (%, N)33,3 % (5)
previous PCI (%, N)33,3 % (5)
previous CABG (%, N)60,0 % (9)
patent LIMA graft (%, N)53,3 % (8)
patent venous grafts aorta (%, N)53,3% (8)

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