Brachiocephalic Artery Access for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is increasing in popularity for symptomatic severe aortic stenosis. Transfemoral arterial route is the most commonly used approach for TAVR, also known as TAVI or transcatheter aortic valve implantation. It does not involve open heart surgery which is otherwise needed for surgical aortic valve replacement. But some patients with unhealthy femoral or iliac arteries need alternative approaches for TAVR. Alternate approaches in such cases include transapical route with direct puncture of left ventricular apex through a mini thoracotomy, trans-ascending aortic approach which needs either a limited sternotomy or thoracotomy, axillary, and carotid arterial approaches. Caval approach is the least preferred because of higher access site complications.

Brachiocephalic artery access without sternotomy for TAVR has been described as a Cutting-Edge Technology in a paper which has been just accepted in the JACC Asia [1]. The paper compared consecutive patients who underwent TAVR for severe aortic stenosis via the brachiocephalic artery without sternotomy and via the ascending aorta with sternotomy or thoractomy, with 10 and 8 patients in each group respectively. ECG triggered multidetector CT images were obtained for preprocedural assessment. If the brachiocephalic artery bifurcation reached the upper rim level of the manubrium or passed slightly across it, suprasternal access without sternotomy was used. Alternate approach was trans ascending aortic with partial sternotomy or right mini thoracotomy.

Trans brachiocephalic artery approach patients had shorter mean procedure time and lower blood loss and shorter duration of hospitalization. Authors noted that it is a safe and feasible alternative for ascending aortic access. They suggested studies with longer follow-up and more patients to confirm their findings. Criteria for brachiocephalic artery access were 1. Brachiocephalic artery diameter 8 mm or more on CT so that 18-F sheath could be inserted and blood flow could occur through the gap between the sheath and the vessel 2. Absence of brachiocephalic artery occlusion which will increase the risk of intraprocedural cerebral ischemia 3. No calcifications in the artery causing vascular stenosis. Contralateral or left atherosclerosis in the carotid artery with significant stenosis or occlusion was a contraindication for this approach.

Reference

1. Takehiko Matsuo, Takeshi Shimamoto, Yasushi Fuku, Masanobu Ohya, Kazushige Kadota, and Tatsuhiko Komiya. Brachiocephalic Artery Access Without Sternotomy in Older Asian Patients Undergoing Transcatheter Aortic Valve Replacement. JACC: Asia. May 14, 2024. Epublished DOI: 10.1016/j.jacasi.2024.03.006