Alternative transarterial access for CoreValve transcatheter aortic bioprosthesis implantation

Abstract

Transcatheter aortic valve implantation (TAVI) is used to treat elderly patients with severe aortic stenosis who are considered extremely high-risk surgical candidates. The safety and effectiveness of TAVI have been demonstrated in numerous studies. The self-expanding CoreValve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) was the first transcatheter aortic valve to be granted the Conformité Européene (CE) mark in May 2007 for retrograde transfemoral implantation. However, TAVI patients are also often affected by severe iliofemoral arteriopathy. In these patients, the retrograde transfemoral approach carries a high risk of vascular injury, making this approach unusable. Alternative arterial access sites, such as the subclavian artery, the ascending aorta, and the carotid artery, have been used for retrograde implantation of the CoreValve bioprosthesis. In the present report, we present the procedural considerations, risks, and benefits of the different types of arterial access used to implant the CoreValve bioprosthesis.

Keywords:

• aortic stenosis
• catheter-based valve intervention
• CoreValve
• structural heart disease
• transcatheter technique

Acknowledgement

We would like to thank Janice Hoettels, for her copyediting assistance.

Financial & competing interests disclosure

G Bruschi is a consultant for Medtronic and Direct Flow; T Modine is a consultant for Medtronic; F De Marco is a consultant for Direct Flow. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. We would like to thank Janice Hoettels, PA, MBA for her copyediting assistance.

Key issues

• Transcatheter aortic valves have been designed to treat high risk for surgery symptomatic aortic stenosis in elderly patients; more than 90,000 patients have undergone transcatheter aortic valve implantation worldwide.

• At the beginning of the experience, the only access was the retrograde approach from the common femoral artery, but due to the large device size, the trans-femoral approach requires favorable ileo-femoral arterial anatomy; moreover, this approach is contraindicated in patients with excessive atherosclerosis, calcifications or tortuosity of ileo-femoral arteries.

• Since 2008, different alternative arterial access has been used for CoreValve implantation; in patients not suitable for peripheral femoral approach, the subclavian artery direct aortic access and a trans-carotid one.

• All non-iliofemoral and proximal arterial accesses had the advantage that the control of the delivery system is dramatically enhanced because any force is directly transmitted one-to-one without any loss of pushability and trakability compared to a trans-femoral approach. This undoubtedly facilitates more accurate valve deployment.

• To treat patients via alternative access routes, the cooperation between cardiologists, cardiac surgeons, anesthesiologists, echocardiographist, radiologists, nurses and all different specialists involved in transcatheter aortic valve implantation patients’ care (the so-called heart team) is crucial.