Transaxillary Cut-down versus Transfemoral Access in TAVI

Background: The transfemoral (TF) access exclusively has a class I indication for TAVI in current guidelines, while a non-TF TAVI approach is only indicated when not suitable for surgical aortic valve replacement. The transaxillary (TAX) access is of interest for patients with iliofemoral atherosclerotic disease, small iliofemoral diameters, and tortuous vessels in whom TF access is not feasible. It remains important for the heart teams to offer alternative surgical access modalities for patients not amenable to the standard TF-TAVI approaches and avoiding a transapical access.

Methods: A total of 2,069 patients who underwent TAVI for high-grade calcified aortic valve stenosis between 01/2020 and 08/2023 were studied. Patients not suitable for TF access route were treated by a TAX approach. A risk-adjusted propensity score match (1:1 PSM, Caliper 0.2) and retrospective analysis of TF and TAX approach for TAVI with 130 patients in each group were performed.

Results: Despite PSM for preoperative characteristics, risk scores including EuroSCORE II (4.5 ± 3.8 vs. 5.9 ± 4.1; p < 0.001) and STS-Score (4.1 ± 4.2 vs. 5.6 ± 6.7; p = 0.006) still differed significantly between TF- and TAX-TAVI patients. Self-expandable prosthesis (69% vs. 80%; p = 0.042) in combination with a valvuloplasty (56% vs. 70%; p = 0.027) were used more often when a TAX approach was chosen. Postoperative outcomes with respect to mortality rates (2.3% in both groups), TIA/stroke (3.4% vs. 6.1%, p = 0.332), new permanent pacemaker implantation (12% vs. 13%, p = 0.852), and relevant paravalvular leakage (3.3% vs. 0.0%, p = 0.058) did not differ between TF- and TAX-TAVI. During mid-term follow-up, all-cause mortality (8.0% vs. 13%, p = 0.175) and stroke rates (1.5% vs. 2.3%, p = 0.875) did not differ.

Conclusion: In the reported cohort, TAX-TAVI patients presented with a higher perioperative risk but comparable postoperative and follow-up outcomes. In patients not suitable for transfemoral approach, it is reasonable to consider TAX access first without constraints regarding the choice of prosthesis and the possibility of avoiding general anesthesia.

Publication History

Article published online:
11 February 2025