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Cleveland Clinic Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
(Email: roselle{at}ccf.org).
| Dr Roselli discloses that he has financial relationships with Edwards Lifesciences, Medtronic, Direct Flow, and Apica.
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Transcatheter aortic valve replacement (TAVR) has quickly established a role in the treatment of severe aortic stenosis in the highest risk surgical patients. As the techniques and devices have evolved, it is expected that outcomes will continue to improve. Early on it was clear that vascular or transapical access complications were inversely associated with both early and late survival [1]. A more refined imaging screening process and a reduction in the profile of the delivery systems represent some of the iterative improvements directed at limiting these devastating complications. Unfortunately, vascular access complications continue to occur because of patient factors. Alternative access approaches such as the use of the axillary artery or direct aortic placement have been explored to further reduce risk with reasonable success [2].
Modine and colleagues [3] present yet another option for safe delivery and deployment of transcatheter aortic valves. They describe their initial experience with 12 patients who underwent TAVR through a small cervical incision and direct access into the common carotid artery. There were no deaths and only 1 stroke, and all devices were delivered and deployed successfully.
Although the experience is small and the follow-up short, it demonstrates once again that the safe performance of TAVR is dependent on careful imaging-based planning. The authors stress the importance of understanding the cervical and intracranial circulation using preoperative imaging with ultrasonography and cross-sectional imaging of the circle of Willis. By adopting a multidisciplinary heart-team approach to these patients, we should strive for zero tolerance of serious complications due to vascular access issues [4].
The authors selected the patients in this series for the transcarotid approach based on their high-risk vascular access. Even with smaller sheaths, the burden of atherosclerotic occlusive disease and the remoteness of access to the aortic valve may be prohibitive from the iliofemoral arteries. The transapical or transaortic approach may not be well tolerated by patients with comorbid pulmonary disease. In patients dependent on coronary perfusion from an internal thoracic bypass graft, the transaxillary approach is relatively contraindicated. All of the patients in this series had patent internal thoracic artery grafts. Furthermore, the proximal subclavian artery is more likely to be excessively tortuous than the common carotid artery and so may be at more risk for vascular injury.
Complications were not completely eliminated with the transcarotid approach, as 1 patient did suffer a stroke and some patients did have perivalvular leaks. Although these results are excellent, it is also a population with relatively low Society of Thoracic Surgeons scores, averaging 6% for mortality.
When it comes to providing the safest and most durable treatment for severe aortic stenosis, there is not 1 procedure or approach that fits all patients equally well. The physicians who are best suited to providing care for these patients will understand the benefits and limitations of each and tailor the specific care for each individual. TAVR should know no access limitations. As cardiovascular surgeons, it is critical to be involved in every aspect of the treatment process: patient and procedure selection, device delivery and deployment, perioperative care, and follow-up.
Modine and colleagues are to be congratulated for demonstrating the feasibility of yet another option in the safe care of these complex patients. As more data become available, the next challenge to all of us is to understand when and how to apply the various options to each patient so that we may provide the best care. I look forward to seeing more results of the various approaches and devices once a fair comparison can be made over a period of late follow-up, especially with alternative access approaches like the 1 demonstrated here.
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