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Vascular Access in Patients With Peripheral Arterial Disease Undergoing TAVR: The Hostile Registry.

JACC. Cardiovascular interventions

Authors: Tullio Palmerini, Francesco Saia, Won-Keun Kim, Matthias Renker, Alessandro Iadanza, Massimo Fineschi, Antonio Giulio Bruno, Gabriele Ghetti, Maarten Vanhaverbeke, Lars Søndergaard, Ole De Backer, Enrico Romagnoli, Francesco Burzotta, Carlo Trani, Rik Adrichem, Nicolas M Van Mieghem, Elena Nardi, Francesco Chietera, Mateusz Orzalkiewicz, Daijiro Tomii, Thomas Pilgrim, Tiziana Claudia Aranzulla, Giuseppe Musumeci, Matti Adam, Max M Meertens, Nevio Taglieri, Cinzia Marrozzini, Hector Alfonso Alvarez Covarrubias, Michael Joner, Giulia Nardi, Francesca Maria Di Muro, Carlo Di Mario, Lucca Loretz, Stefan Toggweiler, Enrico Gallitto, Mauro Gargiulo, Luca Testa, Francesco Bedogni, Sergio Berti, Marco B Ancona, Matteo Montorfano, Alessandro Leone, Carlo Savini, Davide Pacini, Jonas Gmeiner, Daniel Braun, Roberto Nerla, Fausto Castriota, Marco De Carlo, Anna Sonia Petronio, Marco Barbanti, Giuliano Costa, Corrado Tamburino, Pier Pasquale Leone, Bernhard Reimers, Giulio Stefanini, Mitsumasa Sudo, Georg Nickenig, Tommaso Piva, Andrea Scotti, Azeem Latib, Matteo Vercellino, Italo Porto, Pablo Codner, Ran Kornowski, Antonio L Bartorelli, Giuseppe Tarantini, Chiara Fraccaro, Mohamed Abdel-Wahab, Eberhard Grube, Nazzareno Galié, Gregg W Stone

BACKGROUND: The optimal access route in patients with severe peripheral artery disease (PAD) undergoing transcatheter aortic valve replacement (TAVR) remains undetermined.

OBJECTIVES: This study sought to compare clinical outcomes with transfemoral access (TFA), transthoracic access (TTA), and nonthoracic transalternative access (TAA) in TAVR patients with severe PAD.

METHODS: Patients with PAD and hostile femoral access (TFA impossible, or possible only after percutaneous treatment) undergoing TAVR at 28 international centers were included in this registry. The primary endpoint was the propensity-adjusted risk of 30-day major adverse events (MAE) defined as the composite of all-cause mortality, stroke/transient ischemic attack (TIA), or main access site-related Valve Academic Research Consortium 3 major vascular complications. Outcomes were also stratified according to the severity of PAD using a novel risk score (Hostile score).

RESULTS: Among the 1,707 patients included in the registry, 518 (30.3%) underwent TAVR with TFA after percutaneous treatment, 642 (37.6%) with TTA, and 547 (32.0%) with TAA (mostly transaxillary). Compared with TTA, both TFA (adjusted HR: 0.58; 95% CI: 0.45-0.75) and TAA (adjusted HR: 0.60; 95% CI: 0.47-0.78) were associated with lower 30-day rates of MAE, driven by fewer access site-related complications. Composite risks at 1 year were also lower with TFA and TAA compared with TTA. TFA compared with TAA was associated with lower 1-year risk of stroke/TIA (adjusted HR: 0.49; 95% CI: 0.24-0.98), a finding confined to patients with low Hostile scores (P = 0.049).

CONCLUSIONS: Among patients with PAD undergoing TAVR, both TFA and TAA were associated with lower 30-day and 1-year rates of MAE compared with TTA, but 1-year stroke/TIA rates were higher with TAA compared with TFA.

Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

PMID: 36858659

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