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Proximal Arterial Access in TAVR: the Case for the Innominate Artery
Mark A. Groh1, William B. Abernethy2, Joshua P. Leitner2, Gerard L. Champsaur2.
1Asheville Heart, Asheville, NC, USA, 2Mission Hospital, Asheville, NC, USA.

OBJECTIVE: We initiated a systematic approach of proximal arterial access (PAA) over transapical implantation (TA) for alternative access TAVR. Early in our PAA experience, we favored transaortic (TAo) approach but we have increasingly employed the innominate artery (TI), offering a less invasive alternative. We review here our current experience.
METHODS: Between 2/7/2012 and 10/10/2015, we performed a continuous series of 168 TAVR procedures. Due to safety concerns with TA (n=8), and our familiarity with aortic cannulation, we began performing all alternative access procedures via TAo. In the second year, for the sake of minimal invasiveness, we initiated TI access through incision limited to the manubrium without the need for a “J” incision. Proximal and distal control is gained on the innominate artery and wire access is gained through direct puncture. After crossing the valve, the introducer and sheath are advanced across the valve and the introducer is removed, allowing the valve to be placed into the outflow tract without balloon valvuloplasty. After valve deployment, the sheath is removed with rapid pacing and the arteriotomy is closed in transverse fashion.
RESULTS: PAA has been employed in 90 patients (56 TAo and 34 TI) with increasing TI share as shown in Figure 1. Our PAA patients have higher STS risk scores than TF patients (8.93 vs. 6.58, p=0.002). Compared to TF (n=70), PAA are significantly shorter procedures, have less radiation exposure and require less contrast, with no significant difference between TI and TAo. There were no differences in stroke or early mortality (4.0% vs 4.44%, p=0.96) between PAA and TF. Device success was 85.71% for TF and 95.55% for PAA (p=0.002), with no difference between TAo and TI.
CONCLUSIONS: The TI approach, similar to TAo, offers highly reliable valve implant success rates and short procedure times with a less invasive approach. The added proximity of the aortic valve may make TI the access of choice for PAA TAVR.

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