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Alternative Access In Transcatheter Aortic Valve Implantation
Tine E. Philipsen, Valérie M. Collas, Johan M. Bosmans, Marc J. Claeys, Inez E. Rodrigus.
UZA - Antwerp University Hospital, Edegem, Belgium.

Introduction The most common approach in transcatheter aortic valve implantation (TAVI) is no doubt the transfemoral. However, in case of atherosclerosis, small vessels or previous peripheral arterial surgery, transfemoral access is no option. Multiple alternative approaches have been described. In patients not suitable for transfemoral TAVI, we opt for an open approach through either the brachiocephalic artery or the ascending aorta. Methods The brachiocephalic artery can mostly be accessed suprasternally. In case of calcification or small caliber of the brachiocephalic artery or presence of a hostile neck (eg previous cervical surgery), the ascending aorta may be the preferred access site. Results In our series of 179 subsequent TAVI procedures (Medtronic CoreValve®), 148 patients were treated transfemorally. No major vascular complications were seen. In 36 patients (24.3%) minor access related vascular injury necessitated further intervention (surgical repair (4.05%), femoral stenting (11.49%), femoral dilatation (4.05%), thrombin injection (4.73%)). Thirty-one valves were implanted trough non-femoral access because of severe femoroiliac disease. In our early experience, 9 patients were treated by trans-subclavian access. In one case, periprocedural occlusion of a patent LIMA graft caused myocardial ischaemia, so this approach is no longer our primary choice. More recently, the open brachiocephalic access was successfully used in 15 patients. Eight had previous CABG with patent LIMA grafts, and 14 patients had severe femoroiliac atherosclerosis. In 11 of these patients, the brachiocephalic artery could be accessed suprasternally. Seven valves were implanted by direct aortic access after partial sternotomy in patients with both patent LIMA graft after previous CABG and severe peripheral atherosclerosis. No procedural or vascular complications were seen in the brachiocephalic or direct aortic access. Conclusion TAVI is an accepted alternative to surgical AVR in high risk patients. Brachiocephalic and transaortic access are safe and feasible if transfemoral TAVI is contra-indicated, and might even be valid alternatives for transapical approach. The distance from the brachiocephalic artery or ascending aorta to the aortic valve annulus is small , hereby increasing delivery catheter stability and accurate valve positioning. Up to now, we did not decline any patient for TAVI treatment based exclusively on the absence of suitable access.

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