Vascular access for transcatheter aortic valve replacement: A network meta-analysis

Yujiro Yokoyama; Tomoki Sakata; Takahisa Mikami; Naoki Misumida; Andrea Scotti; Hisato Takagi; Tadahisa Sugiura; Toshiki Kuno; Azeem Latib

doi:10.1016/j.jjcc.2023.04.015

Vascular access for transcatheter aortic valve replacement: A network meta-analysis

J Cardiol. 2023 Oct;82(4):227-233. doi: 10.1016/j.jjcc.2023.04.015. Epub 2023 Apr 26.

Authors

Yujiro Yokoyama¹, Tomoki Sakata², Takahisa Mikami³, Naoki Misumida⁴, Andrea Scotti⁵, Hisato Takagi⁶, Tadahisa Sugiura⁷, Toshiki Kuno⁸, Azeem Latib⁵

Affiliations

¹ Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA.
² Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
³ Department of Neurology, Tufts Medical Center, Medford and Somerville, MA, USA.
⁴ Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, USA.
⁵ Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁶ Department of Cardiovascular Surgery, Shizuoka Medical Center, Shimizu, Shizuoka, Japan.
⁷ Department of Cardiothoracic & Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
⁸ Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. Electronic address: tkuno@montefiore.org.

PMID: 37116649
DOI: 10.1016/j.jjcc.2023.04.015

Abstract

Background: The choice of an alternative access for transcatheter aortic valve replacement (TAVR) remains controversial when transfemoral (TF) access is not feasible.

Methods: We conducted a network meta-analysis to compare the outcomes of TAVR via various peripheral vascular accesses. MEDLINE and EMBASE were searched through July 2022 to identify studies that investigated outcomes in patients who underwent TAVR via TF, trans-subclavian (Tsc), transcarotid (TC), or transcaval (Tcav) access. A network meta-analysis was conducted via random-effects model. Outcomes of interest were major or life-threatening bleeding, stroke, major vascular complication, and 30-day mortality.

Results: No randomized trial was identified. Our analysis included 33 observational studies that enrolled a total of 43,455 patients who underwent TAVR via TF (n = 36,202), Tsc (n = 3869), TC (n = 3066), or Tcav (n = 318) access. The risk of major or life-threatening bleeding was higher via Tsc compared with TF [odds ratio (OR); 95 % confidence interval (CI) =1.51 (1.03-2.23), p = 0.034]. The risk of stroke was higher via Tsc compared with TF and Tcav [OR (95 % CI) =2.00 (1.14-3.52), p = 0.018, OR (95 % CI) =2.43 (1.03-5.74), p = 0.044, respectively]. The risk of major vascular complications was lower via TC compared with Tsc, and Tcav and higher with Tcav compared with TF and Tsc. 30-day mortality was higher via Tsc compared with TF. Tsc was associated with higher risk of major or life-threatening bleeding compared with TF, and higher risk of stroke compared to TF and Tcav. Tcav had the highest risk of major vascular complications.

Conclusion: In patients who underwent TF, Tsc, TC, or Tcav TAVR, Tsc had a higher rate of stroke compared to TF and Tcav, and major or life-threatening bleeding compared to TF. The rate of major vascular complications in Tcav was the highest among the four approaches.

Keywords: Trans-subclavian; Transcarotid; Transcatheter aortic valve replacement; Transcaval; Transfemoral.

Publication types

Meta-Analysis

MeSH terms

Aortic Valve / surgery
Aortic Valve Stenosis*
Femoral Artery / surgery
Humans
Network Meta-Analysis
Observational Studies as Topic
Risk Assessment
Risk Factors
Stroke* / epidemiology
Stroke* / etiology
Transcatheter Aortic Valve Replacement* / adverse effects
Treatment Outcome