Transcatheter aortic valve implantation via surgical subclavian versus direct aortic access: A United Kingdom analysis.

Background: Surgical subclavian (SC) and direct aortic (DA) access are established alternatives to the default transfemoral route for transcatheter aortic valve implantation (TAVI). We sought to find differences in survival and procedure-related outcomes after SC- versus DA-TAVI.
Methods: We performed an observational cohort analysis of cases prospectively uploaded to the UK TAVI registry. To ensure the most contemporaneous comparison, the analysis focused on SC and DA procedures performed from 2013 to 2015.
Results: Between January 2013 and July 2015, 82 (37%) SC and 142 (63%) DA cases were performed that had validated 1-year life status. Multivariable regression analysis showed procedure duration was longer for SC cases (SC 193.5 ± 65.8 vs. DA 138.4 ± 57.7 min; p < .01) but length of hospital stay was shorter (SC 8.6 ± 9.5 vs. DA 11.9 ± 10.8 days; p = .03). Acute kidney injury was observed less frequently after SC cases (odds ratio [OR] 0.35, 95% confidence interval [CI 0.12-0.96]; p = .042) but vascular access site-related complications were more common (OR 9.75 [3.07-30.93]; p < .01). Procedure-related bleeding (OR 0.54 [0.24-1.25]; p = .15) and in-hospital stroke rate (SC 3.7% vs. DA 2.1%; p = .67) were similar. There were no significant differences in in-hospital (SC 2.4% vs. DA 4.9%; p = .49), 30-day (SC 2.4% vs. DA 4.2%; p = .71) or 1-year (SC 14.5% vs. DA 21.9%; p = .344) mortality.
Conclusions: Surgical subclavian and direct aortic approaches can offer favourable outcomes in appropriate patients. Neither access modality conferred a survival advantage but there were significant differences in procedural metrics that might influence which approach is selected.
Competing Interests: Declaration of competing interest Aung Myat, Olympia Papachristofi, Uday Trivedi, Adam de Belder, James Cockburn, Andreas Baumbach, Michael Mullen, Mark de Belder, Ian Cox, Iqbal S. Malik, Peter Ludman and Linda Sharples report no conflicts to declare pertaining to this manuscript. Adrian P. Banning reports institutional funding from Boston Scientific for a Fellowship. Daniel J. Blackman is a Consultant and Proctor for Medtronic and Boston Scientific. Philip MacCarthy declares consulting/proctorship contracts with Edwards Lifesciences and research support from Boston Scientific. Douglas Muir is a Proctor for Edwards Lifesciences and Abbott Vascular. Jan Kovac is a Proctor and Consultant for Edwards Lifesciences, Medtronic, Boston Scientific and Abbott. Stephen Brecker is a Clinical Advisor/Consultant for Medtronic, Boston Scientific and Abbott. Mark Turner is a proctor for Medtronic pulmonary valves currently, and has been a proctor for Edwards Lifesciences pulmonary valves in the past, but no longer holds a contract with them. He is also a Consultant and Advisory Board Member for St Jude (now Abbott), and has previously received educational meeting support from Edwards Lifesciences, Medtronic and Abbott. Saib Khogali is a Proctor for Boston Scientific and Medtronic. Simon Redwood declares Proctor and Lecture fees from Edwards Lifesciences. Bernard Prendergast declares unrestricted research grants and lecture fees from Edwards Lifesciences. David Hildick-Smith has advisory and proctoring contracts with Boston Scientific, Edwards and Medtronic.
(Copyright © 2020. Published by Elsevier B.V.)