Introduction
The transfemoral (TF) approach is the established default vascular
access for transcatheter aortic valve implantation
(TAVI)1,2. However, small vessel calibre and/or
peripheral vascular disease
(calcification, previous stenting
deployment, tortuosity, pathological stenosis) may preclude femoral TAVI
in a significant number of patients3. Despite the
miniaturization of transcatheter aortic valve delivery systems, it is
estimated that 10% to 15% of patients will still have unsuitable
ileo-femoral arteries for TAVI4. Alternative
approaches are transapical (TA), direct aortic (DA), subclavian/axillary
(SC), carotid, and transcaval approach5. In the
timeline, the TA access was the first one alternative which was
developed, but it had high rate of bleeding and mortality compared to
TF6, so in 2008 was described the first SC
implantation route for transcatheter aortic valve, which was aiming to
address the TA downsides7. Currently, the TA TAVI is
performed less frequently in the United Kingdom (UK)8.
Consequently, the SC/axillary is becoming the predominant alternative
access approach9. Because trials data recommend TAVI
for high-, intermediate-, and even low-risk operable
patients10 and because there is a lack of data
prospectively comparing outcomes after SC vs TA TAVI, it is useful to
analyse the UK TAVI registry to determine whether there was a difference
in procedural- related complications according to Valve Academic
Research Consortium-2 (VARC-2) criteria, and in short-, medium-, and
long-term survival between these main two alternative vascular
approaches, which are fundamental in case of femoral contraindication
for TAVI delivery. In this regard, the aim of this study was to compare
complications and morbidity/mortality associated with TA and SC, which
are the main choice for TAVI when TF is precluded in a real-world
long-time national data setting.