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International Society For Minimally Invasive Cardiothoracic Surgery

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Carotid Artery As An Alternative Access Route For Trancatheter Aortic Valve Implantation
Damian Hudziak1, Radosław Gocoł1, Wojciech Wojakowski2, Andrzej Ochała2, Radosław Parma2, Joanna Ciosek1, Leszek Machej2, Michał Lelek1, Marek A. Deja2.
1Upper Silesian Heart Center, Katowice, Poland, 2Medical University of Silesia, Katowice, Poland.

Objective. Transfemoral (TF) is the most commonly used access for TAVI due to the best safety profile and favorable long-term outcomes. Alternative access must be used in 15-20% of TAVI candidates due to significant peripheral artery disease (PAD) and significant descending aortic disease. TAVI procedure through the common carotid artery (CCA) seems to be a promising alternative approach, for high-vascular-risk patients. Methods. The approach was selected by a multidisciplinary (cardiologists and cardiac surgeons) heart team after analyzing preoperative coronary angiography, TTE and MSCT of the peripheral arteries. Patients with the following conditions were qualified to the transcarotid access: severe PAD (stenotic, heavily calcified), tortuous or small diameter < 6 mm iliofemoral arteries, descending and abdominal aortic disease (an aneurysm, thrombus, stentgraft). Results. Thirty-three TC TAVI procedures were performed in our hospital from September 2017 to November 2019. Twenty four patients received EvoluteR, 8 Sapien and 1 Portico valve. There was one in-hospital death not related to access (ruptured aortic ring) and one cerebrovascular complication (TIA). The procedural success rate defined as the implantation of the valve with no coronary obstruction and less than moderate paravalvular leak (PVL) was 94%. Parameters of regional cerebral oximetry were symmetrical on the left and right side in all cases and only during rapid ventricular pacing transiently decreased below the value of 50%. Postoperative myocardial infarctions was not observed. Statistically significant reduction of the echocardiographic parameters (PGmax and PGmean, Vmax) were observed. Mild paravalvular leaks occurred in 13 patients. Additionally, the heart failure symptoms diminished after the procedure from a median class III to class II. Other postoperative data are included in the table. Conclusion. Our results show that TC approach is feasible and safe. With proper preprocedural imaging and planning as well as patients selection TC access became our first-choice alternative approach for TAVI.
Table. Postoperative outcomes

Postoperative outcomes
Mortality (30 days)1 (3%)
Moderate PVL2 (6%)
Stroke0
TIA1 (3%)
Pacemaker implantation6 (18%)
Myocardial infarction0
Bleeding0
Tamponade0
Wound infection0
Hospital stay6.250.87 days


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