Transcaval access TAVR

Do you know this access route?

Transcatheter deployment of an aortic prosthesis, also known as TAVR, has become a widespread procedure worldwide, including recent publications in patients at low surgical risk.

The transfemoral approach, in the vast majority of the studied cohorts, was the one that presented the best evolutionary results, having indication with greater evidence than the thoracic accesses such as the transapical or through the subclavian or axillary.

What if it is impossible to use this access route?

In 2014, a new access route was suggested as a possibility in patients with extensive vascular disease: the transcaval approach. Initially, access occurs via the femoral venous route and when the guide is in the inferior vena cava, transfixation occurs through the retroperitoneal space to the aortic artery and then it proceeds to the height of the aortic valve.

As risky as perforating large vessels in the retroperitoneum seems, the initial data from the European and American cohort studies do not point out relevant acute hemorrhagic complications or that require readmission. Half of the cases have some degree of shunt, but the pressure of the retroperitoneum itself helps to prevent this bleeding. The plugs used for puncture site occlusion in the aorta also prove to be safe and in rare cases there are complications.

What this access route shows us is that it would be another alternative in cases of patients with severe vasculopathies, who do not have adequate arterial accesses. With what we have of data currently in the literature, TAVI performed by transcaval route is safe and presents good results when compared to the largest studies that use conventional femoral access.

A point that deserves to be highlighted is that, in general, these patients are at high surgical risk and with several comorbidities, and they should not yet extrapolate these findings to groups of low-risk patients. We must also draw attention to the technical difficulty inherent in this new approach, because compared to the transfemoral approach, transcaval has a much smaller number of patients submitted worldwide.

Suggested literature:  

1 – Costa G, De Backer O, Pilgrim T, et al. Initial European experience with transcaval transcatheter aortic valve implantation. EuroIntervention. 2019 Oct 29. pii: EIJ-D-19-00797.

 

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