Carotid Access for TAVR: An underappreciated approach?

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Presentation transcript:

Carotid Access for TAVR: An underappreciated approach? Christian Shults, MD

Christian Shults, MD I have no relevant financial relationships

Trans-femoral Alternative Access Trans-axillary Trans-caval / Trans-aortic Trans-apical Trans-Carotid

Staying out of the chest Intrathoracic access associated with: increased length of stay increased cost slower recovery increased 30 day and 1 year mortality.

Patients Selected for TransCarotid TAVR Patient #1: Moderate-Severe COPD, Porcelain, Frail, Jehovah’s Witness Patient #2: 6 previous sternotomies, Congenital Bicuspid Valve (Shone’s Complex), homograft failure, Severe LV dysfunction Patient #3: Severe COPD, Porcelain Aorta, Previous CABG, Severe LV dysfunction Patient #4: Severe COPD, Porcelain Aorta, Frail Patient #5: Severe COPD, Severe renal failure, Previous CABG, Frail

Screening MSCT Centerline dimensions of the carotid, subclavian and vertebral arteries Minimal Diameter 6.0 mm Origin of innominate/carotid for atherosclerosis/stenosis Common or internal carotid artery stenosis/Plaques Congenital variants of aortic arch (Bovine) Prior ipsilateral intervention Contralateral occlusion or stenosis or occlusion of the vertebral arteries MRA: Delineate the components of the circle of willis

Intra-op Cerebral Oximetry EEG monitoring SBP > 100mmHg (Near infrared spectrometry) EEG monitoring SBP > 100mmHg General vs. Awake Awake - test clamping for 3 minutes Symptomatic Femoro-carotid shunt

Transcarotid TAVR Concept Cerebral Bypass Circuit SHUNT SHEATH

Transcarotid TAVR

Transcarotid TAVR

Transcarotid TAVR

Transcarotid TAVR Easy Access Hemodynamically Tolerated Good Control with Deployment Minimal Blood Loss Easy Repair (Patch or Direct)

Transcarotid TAVR

Emory Transcarotid TAVR Experience 30- day outcomes N=14 Success 100% 30 day Mortality Bleeding Vascular Complications Renal Failure PVL > Grade 1 Clinical Stroke

French Transcarotid TAVR Registry 174 patients 122 general, 52 minimally invasive 30 day mortality 7% All cause cardiovascular 1 year mortality 12% and 8% respectively 5.7% had VARC-2-defined cerebrovascular events ( all in the general anesthesia group) Debry et al

Transcarotid TAVR Utilizing EEG Guided Selective Cerebral Perfusion 14 patients Median STS 11% (range 3-21) Both right (10) and left (4) carotid access utilized Procedural success - 100%. No patient required femoral to carotid shunting 93% (13/14) a transverse carotid arteriotomy with primary repair No in hospital/30 day deaths or strokes. Complications pericardial effusion,surgical drainage (n=1), pacemaker (n=2), valve in valve for PV leak (n=1) carotid conduit constructed following retrieval of a malfunctioning valve (n=1). Median length of stay was 3 days (range 1-9) All patients discharged home. Median follow up of four months (range 2-7 months) survival remains 100% with no late carotid access complications or strokes Allen et. Al.

Follow up Doppler imaging of carotid prior to discharge

Conclusion Carotid access is safe Easily accessed and controlled Usually free of disease Careful assessment with MSCT critical Can be done under MAC/Local Results as good as TF