Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients: Initial human experience

Adam B. Greenbaum, William W. O'Neill, Gaetano Paone, Mayra Guerrero, Janet F. Wyman, R. Lebron Cooper, Robert J. Lederman

Research output: Contribution to journalArticle

91 Citations (Scopus)

Abstract

Objectives This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. Background TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. Methods We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access. Results Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract. Conclusions Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.

Original languageEnglish (US)
Pages (from-to)2795-2804
Number of pages10
JournalJournal of the American College of Cardiology
Volume63
Issue number25 PART A
DOIs
StatePublished - Jul 1 2014
Externally publishedYes

Fingerprint

Venae Cavae
Blood Vessels
Transcatheter Aortic Valve Replacement
Femoral Vein
Abdominal Aorta
Aortic Valve Stenosis
Inferior Vena Cava
Blood Transfusion
Aorta

Keywords

  • caval-aortic
  • extra-anatomic procedures
  • transcatheter aortic valve replacement
  • transcaval

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients : Initial human experience. / Greenbaum, Adam B.; O'Neill, William W.; Paone, Gaetano; Guerrero, Mayra; Wyman, Janet F.; Cooper, R. Lebron; Lederman, Robert J.

In: Journal of the American College of Cardiology, Vol. 63, No. 25 PART A, 01.07.2014, p. 2795-2804.

Research output: Contribution to journalArticle

Greenbaum, Adam B. ; O'Neill, William W. ; Paone, Gaetano ; Guerrero, Mayra ; Wyman, Janet F. ; Cooper, R. Lebron ; Lederman, Robert J. / Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients : Initial human experience. In: Journal of the American College of Cardiology. 2014 ; Vol. 63, No. 25 PART A. pp. 2795-2804.
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abstract = "Objectives This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. Background TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. Methods We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access. Results Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79{\%} were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11{\%}) of whom required intervention. Most (79{\%}) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94{\%}) had complete closure of the residual aorto-caval tract. Conclusions Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.",
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T2 - Initial human experience

AU - Greenbaum, Adam B.

AU - O'Neill, William W.

AU - Paone, Gaetano

AU - Guerrero, Mayra

AU - Wyman, Janet F.

AU - Cooper, R. Lebron

AU - Lederman, Robert J.

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N2 - Objectives This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. Background TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. Methods We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access. Results Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract. Conclusions Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.

AB - Objectives This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. Background TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. Methods We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access. Results Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract. Conclusions Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.

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