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OBJECTIVE:
The most common approaches in transcatheter aortic valve implantation (TAVI) are the transfemoral and the transapical way. However, some patients require alternative access methods. We describe the methods we use and possible complications.
METHODS: In case of excessive iliac or femoral vascular disease, access trough open arteriotomy of the subclavian artery can be an option if there is no subclavian stenosis or calcification. However, if these patients have had previous CABG with patent left mammary artery (LIMA) graft, this subclavian way is not ideal because of possible obstruction of the LIMA and subsequent cardiac ischemia during the procedure. In these cases, we now use an open approach trough ministernotomy with direct cannulation of the ascending aorta or the innominate artery, during which cerebral perfusion is continuously monitored.
RESULTS:
In our series of 100 subsequent TAVI procedures (Medtronic CoreValve®), 6 valves were implanted by open subclavian access. All 6 patients had severe femoroiliac arterial disease and 3 had previous CABG. The subclavian artery is surgically exposed, after which the 18 French arterial sheet is placed by Seldinger technique and the valve is introduced. Only in 1 patient, transient periprocedural ischemia was seen due to occlusion of a patent LIMA bypass by the sheet. No other complications were seen.
In 4 patients, all after previous CABG with patent LIMA, the open aortic way was the only possible access. After partial upper sternotomy, a 9 Fr sheet is placed directly in the ascending aorta or in the innominate artery if possible. After crossing the aortic valve with a stiff Amplatz guidewire, the 18Fr sheet is inserted, followed by CoreValve® deployment. We saw no procedural complications. One patient needed thrombin injection of a pseudo aneurysm of an intercostal artery at the location of a previous thoracic drainage tube 4 months postoperatively.
CONCLUSIONS:
Both subclavian and transaortic access are safe and feasible procedures in case of contra-indications for transfemoral TAVI. They might even be promising alternatives for transapical approach in patients with poor femoral access.