Caval-Aortic Access to Allow Transcatheter Aortic Valve Replacement in Patients Otherwise Ineligible: Initial Human Experience

Objectives—We describe the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. Background—TAVR is attractive in high risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which risk major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. Methods—We performed a single center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients undergoing TAVR via caval-aortic access. Results—Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access. 79% were women. Caval-aortic access and tract closure was successful in all 19; TAVR was successful in 17. Six patients suffered modified VARC-2 major vascular complications, two (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Through 111 (39–229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto© 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved. Address for Correspondence: Adam B. Greenbaum, MD, K-2 Cardiac Catheterization Laboratory, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI, 48202, USA. Telephone +1-313-916-3875. [email protected]. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access Author Manuscript J Am Coll Cardiol. Author manuscript; available in PMC 2015 July 01. Published in final edited form as: J Am Coll Cardiol. 2014 July 1; 63(25 0 0): 2795–2804. doi:10.1016/j.jacc.2014.04.015. N IH -P A A uhor M anscript N IH -P A A uhor M anscript N IH -P A A uhor M anscript caval flow immediately post procedure. Of 16 who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract. Conclusions—Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.