Transcarotid aortic valve implantation: ‘the 2nd preferred access site for the TAVR’

In this issue, a series entitled ‘Carotid versus femoral access for transcatheter aortic valve replacement: comparable results in the current era’ compared the femoral approach in 400 patients with 100 patients having the transcarotid approach. The results are comparable between the 2 groups at 30 months and the carotid approach is now their second choice after the femoral access [1].

Transcarotid aortic valve implantation (TCAVI) is a new and valuable alternative route, which has been already, described [2]. It offers direct route to the aortic valve and avoids any sternal or thoracic incision. It has been already extensively used in paediatric patients for aortic valve ballooning with excellent results [3]. Its use for high-risk patients with aortic stenosis not suitable for transfemoral valve implantation has to be carefully compared to other alternative access site such as transapical, transaortic, brachiocephalic and subclavian route. It also can be done very quickly and results in less manipulation of the aortic arch compared with transfemoral approach.

This series indicates that TCAVI is safe and feasible in patients with poor femoral arterial access. Early mortality rates are acceptable in this high population. The access is very simple and can be performed with extreme simplicity and safety since the artery is exposed and closed using experienced vascular technique [4]. The transverse incision provides cosmetic benefit with minimal scar residual. We never used carotid bypass or shunting. Using this approach, TCAVI patients experienced minimal TIA or strokes as compared with other vascular access. We never had to convert to another approach and no vascular complications were encountered. The distance between the entry point and the aortic valve is short, which increases stability during aortic valve delivering and improves speed and accuracy.

The carotid approach can be easily performed in patients also with limited pulmonary reserve, and or with poor ejection fraction since no purse string is placed on the heart and no thoracotomy is made. In randomized trial, TAVI was shown to be superior to standard medical therapy in a cohort of inoperable patients and non-inferior to aortic valve replacement in high-risk operable patients. If the femoral access remains our preferred methods since it can be done totally percutaneously, the TCAVI represents actually more than 50% of our alternative route access, the other being the subclavian approach. In a French registry comparing femoral access and carotid access, we showed that despite a higher-risk population in the carotid group both routes had the same initial and midterm mortality [5]. In our unit and in most French units, the apical route has become almost obsolete and the transaortic route is becoming anecdotal.

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