Carotid Access for TAVR An underappreciated approach Christian

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

Christian Shults, MD I have no relevant financial relationships

• Trans-femoral • Alternative Access 1. 2. 3. 4. 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 Trans. Carotid 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 – (Near infrared spectrometry) • • EEG monitoring SBP > 100 mm. Hg General vs. 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 Success 30 day Mortality Bleeding Vascular Complications Renal Failure PVL > Grade 1 Clinical Stroke N=14 100% 0 0 0

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