The Carotid Artery as a Preferred Alternative Access Route for Transcatheter Aortic Valve Replacement Eric B. Kirker, MD, Robert W. Hodson, MD, Kateri.

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The Carotid Artery as a Preferred Alternative Access Route for Transcatheter Aortic Valve Replacement Eric B. Kirker, MD, Robert W. Hodson, MD, Kateri J. Spinelli, PhD, Ethan C. Korngold, MD The Annals of Thoracic Surgery Volume 104, Issue 2, Pages 621-629 (August 2017) DOI: 10.1016/j.athoracsur.2016.12.030 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Algorithm for determining transcatheter aortic valve replacement (TAVR) access route. (EF = ejection fraction; LCCA = left common carotid artery; RCCA = right common carotid artery; SCA = subclavian artery; TA = transapical; TAo = transaortic; TC = transcarotid; TF = transfemoral.) The Annals of Thoracic Surgery 2017 104, 621-629DOI: (10.1016/j.athoracsur.2016.12.030) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Surgical exposure and access to common carotid artery. (A) Carotid stump pressure distal to clamp was checked to ensure mean arterial pressure >32 mm Hg. (B) A micropuncture needle was used to enter carotid artery, followed by insertion of 6F sheath. (C) After aortic valve crossing, valve delivery sheath was placed. (D) Transcatheter aortic valve replacement (TAVR) valve was passed through delivery sheath into position. The Annals of Thoracic Surgery 2017 104, 621-629DOI: (10.1016/j.athoracsur.2016.12.030) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Surgical repair and recovery from transcarotid transcatheter aortic valve replacement (TC-TAVR). (A–C) Transverse repair of carotid artery, with distal and proximal clamps in place. (D) Small incision site and minimal scarring 7 days postoperatively. The Annals of Thoracic Surgery 2017 104, 621-629DOI: (10.1016/j.athoracsur.2016.12.030) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Valve types successfully deployed for transcarotid transcatheter aortic valve replacement (TC-TAVR). Measurements in each pie piece indicate different diameters used for each valve type, with number of patients included in parentheses. The Annals of Thoracic Surgery 2017 104, 621-629DOI: (10.1016/j.athoracsur.2016.12.030) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Procedural outcomes were better for patients who underwent transcarotid (TC) and transfemoral (TF) procedures compared topatients who underwent transapical (TA) procedures. All data were nonparametric and were analyzed using Wilcoxon rank sum tests (∗p < 0.05; ∗∗p < 0.01; ∗∗∗p < 0.001). (ICU = intensive care unit; LOS = length of stay; ns = not significant; Post-op = postoperative.) The Annals of Thoracic Surgery 2017 104, 621-629DOI: (10.1016/j.athoracsur.2016.12.030) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions