Circulation: Cardiovascular Interventions

ORIGINAL ARTICLE

Transcarotid Compared With Other

Alternative Access Routes for
Transcatheter Aortic Valve Replacement

See Editorial by Praz and Wenaweser Chekrallah Chamandi, MD

Ramzi Abi-Akar, MD
BACKGROUND: The optimal access for patients undergoing Josep Rodés-Cabau, MD
transcatheter aortic valve replacement (TAVR) who are not candidates for Didier Blanchard, MD
a transfemoral approach has not been elucidated. The purpose of this Eric Dumont, MD
Christian Spaulding, MD
study was to compare the safety, feasibility, and early clinical outcomes of
Daniel Doyle, MD
transcarotid TAVR compared with thoracic approaches.
Jean-Yves Pagny, MD
METHODS AND RESULTS: From a multicenter consecutive cohort of 329 Robert DeLarochellière,
alternative-access TAVR patients (2012–2017), we identified 101 patients MD
Antoine Lafont, MD
who underwent transcarotid TAVR and 228 patients who underwent a
Jean-Michel Paradis, MD
transapical or transaortic TAVR. Preprocedural success and 30-day clinical
Rishi Puri, MD
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outcomes were compared using multivariable propensity score analysis Nicole Karam, MD
to account for between-group differences in baseline characteristics. Frédéric Maes, MD
All transcarotid cases were performed under general anesthesia, mainly Tania Rodriguez-Gabella,
using the left common carotid artery (97%). Propensity-matched MD
groups had similar rates of 30-day all-cause mortality (2.1% versus Stéphan Chassaing, MD
4.6%; P=0.37), stroke (2.1% versus 3.5%; P=0.67; transcarotid versus Olivier Le Page, MD
transapical/transaortic, respectively), new pacemaker implantation, Dimitri Kalavrouziotis,
and major vascular complications. Transcarotid TAVR was associated MD*
with significantly less new-onset atrial fibrillation (3.2% versus 19.0%; Siamak Mohammadi, MD*
P=0.002), major or life-threatening bleeding (4.3% versus 19.9%;
P=0.002), acute kidney injury (none versus 12.1%; P=0.002), and shorter
median length of hospital stay (6 versus 8 days; P<0.001).
CONCLUSIONS: Transcarotid vascular access for TAVR is safe and feasible
and is associated with encouraging short-term clinical outcomes. Our
data suggest a clinical benefit of transcarotid TAVR with respect to
atrial fibrillation, major bleeding, acute kidney injury, and length of stay
compared with the more invasive transapical or transaortic strategies.
Randomized studies are required to ascertain whether transcarotid TAVR
yields equivalent results to other alternative vascular access routes. *Drs Kalavrouziotis and Mohammadi
contributed equally to this work.

Key Words:  aortic valve ◼ cohort

studies ◼ heart valve prosthesis
◼ humans ◼ propensity score

© 2018 American Heart Association, Inc.

https://www.ahajournals.org/journal/
circinterventions

Circ Cardiovasc Interv. 2018;11:e006388. DOI: 10.1161/CIRCINTERVENTIONS.118.006388 November 2018 1

 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR
WHAT IS KNOWN
• Transfemoral transcatheter aortic valve replace-
ment (TAVR) is associated with excellent outcomes
in patients with intermediate and high surgical risk.
• Up to 1 in 5 patients may not be candidates for
transfemoral access because of anatomic reasons.
• Transcarotid access is a safe and feasible option
for TAVR, but its merits relative to transthoracic
alternative access options are not clearly known.
WHAT THE STUDY ADDS
• Transcarotid TAVR is safe compared with
transthoracic access with comparable mortality
and stroke risk.
• Transcarotid TAVR may offer several advantages
over transthoracic TAVR, including lower rates of
atrial fibrillation, major bleeding, and renal failure,
as well as reduced hospital stay.
T
ranscatheter aortic valve replacement (TAVR) has
become a reasonable alternative to surgical aortic
valve replacement for patients with severe symp-
tomatic aortic stenosis who are at intermediate-to-high/
prohibitive surgical risk.1–3 Although transfemoral access
is considered the default access strategy, 10% to 15% of
TAVR candidates do not have favorable iliofemoral anat-
omy for safe transfemoral access.4 As experience with
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alternative access routes is growing, transcatheter heart
valve (THV) technologies have evolved considerably over
time, and important iterations have been implemented
in many of the latest generation devices to diminish the
proportion of patients deemed to be poor candidates
for transfemoral access.5 However, each access option
has unique advantages and limitations that must be
individualized to the patient’s anatomy.6
The carotid artery has been recently suggested as a
feasible alternative access during TAVR, with encour-
aging short- and medium-term outcomes, harboring
specific advantages over the more invasive transapi-
cal or transaortic strategies.7–11 There are currently
limited comparative data among the alternative TAVR
approaches, and, therefore, we performed a multi-
center comparison between transcarotid and transapi-
cal/transaortic approaches with respect to safety and
early clinical outcomes.
METHODS
The data, analytic methods, and study materials will not be
made available to other researchers for purposes of reproduc-
ing the results because of restrictions imposed by the patient
consent process.
Patient Population
This prospective multicenter, observational registry was
developed following the collaboration of the interventional
Circ Cardiovasc Interv. 2018;11:e006388. DOI: 10.1161/CIRCINTERVENTIONS.118.006388
cardiology and cardiac surgery departments across 3 tertiary-
care hospitals from Canada and France. We identified 329
consecutive TAVR patients who underwent alternative non-
transfemoral approaches including transapical, transaortic,
or transcarotid, between January 2012 and June 2017. A
transapical or transaortic TAVR was performed in 228 cases
(159 transapical and 69 transaortic), whereas the transca-
rotid approach was used in 101 cases. To adjust for poten-
tial differences in patient perioperative risk, patients in the
combined transapical/transaortic TAVR group were matched
to patients in the transcarotid TAVR group using a propensity
score analysis, as described in the statistical analysis section.
The matched final study population consisted of 163 patients
receiving transapical/transaortic TAVR and 94 patients receiv-
ing transcarotid TAVR.
At each participating institution, patients with severe aortic
stenosis considered by the local multidisciplinary heart team
to be at high or prohibitive surgical risk were considered for
TAVR. Multimodality vascular evaluation was performed in
all cases to select the optimal vascular access. Whenever fea-
sible, transfemoral was considered as the first-line approach.
Patients with unfavorable iliofemoral anatomy (minimal lumen
diameter, ≤6 mm; severe calcification/tortuosity), signifi-
cant disease of the thoracoabdominal aorta, or prior periph-
eral arterial interventions were not considered eligible for a
transfemoral approach. Selection of alternative access was
then individualized to each patient’s anatomic features and
comorbidities. However, transcarotid access was the favored
approach during the latter part of the study period, if feasible,
as described below. Transapical and transaortic were reserved
for patients who were not considered candidates for a trans-
carotid approach, with selection between transapical and
transaortic largely based on anatomy and comorbidity (previ-
ous cardiac surgery, severely calcified ascending aorta, left ven-
tricular dysfunction with or without calcified apical aneurysm,
severe chronic lung disease, etc). The yearly proportion of total
TAVR cases that were not transfemoral TAVR in the 3 partici-
pating centers, from January 2012 to June 2017 was 18.4%,
20.1%, 16.7%, 15.4%, 20.9%, and 14.6% (Appendix in the
Data Supplement; Figure I in the Data Supplement). The study
was approved by the institutional review board of each partici-
pating institution. All patients gave written informed consent
for participation in the registry, and this study met the require-
ments of each participating institutional review board.
Preprocedural Screening
All patients referred for TAVR underwent cardiac catheter-
ization (followed by percutaneous revascularization if severe
stenosis or functionally significant intermediate coronary ste-
nosis was detected), as well as cardiac and global vascular
assessment with multislice computed tomography (CT) stud-
ies. Aortic annulus area and perimeter, Valsalva sinus size,
Agatston calcium score, and distance between the aortic
valve annulus and coronary arteries were measured from CT
studies, which informed the decision on the appropriate size
and prosthesis type. In patients not suitable for a transfemoral
approach, the carotid arteries were assessed by Doppler ultra-
sound and multislice CT evaluation of carotid and supra-aortic
arch vessels to detect any functionally significant stenosis or
flow disturbance. Transcarotid access was considered feasible
when the 2 following criteria were satisfied: (1) the presence
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 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR
of a common carotid artery (CCA) minimal lumen diam-
eter ≥7 mm and (2) the absence of a contralateral carotid
artery occlusion, significant (≥50%) internal or CCA stenosis,
and occlusion or stenosis of vertebral arteries. Brain CT or
magnetic resonance imaging were not routinely performed.
Patients with a history of cerebrovascular events were all eval-
uated by a neurologist before the procedure and, if recom-
mended, had further preprocedural imaging.
Procedural Technique
In all cases, TAVR was performed under general anesthe-
sia, with invasive hemodynamic monitoring and continu-
ous cerebral saturation assessment with the INVOS system
(Medtronic, Minneapolis, MN). Additional simultaneous elec-
troencephalogram monitoring was used in 2 of the 3 cen-
ters.12 Radial or femoral arterial access was used for pigtail
guidance to the plane of the aortic valve, and a temporary
pacemaker was implanted either by jugular or femoral vein
access. Fluoroscopic and transesophageal echocardiography
guidance were performed, with unfractionated intravenous
heparin given to achieve an activated clotting time of ≥250
seconds. All patients were receiving at least single-antiplatelet
therapy at the time of TAVR.
Transcarotid TAVR was performed following a previously
published technique.13 To summarize, an intraprocedural
indirect evaluation of the functional integrity of the arterial
circle of Willis and patency of the contralateral CCA were per-
formed in 1 of the 3 centers. For this purpose, the proximal
CCA was clamped during a 2-minute period during which
time the distal arterial pressure and cerebral oximetry were
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measured. A decrease of the mean backflow pressure to <30
mm Hg or a decrease of ≥50% in cerebral saturation during
the clamp test that did not respond to moderate hemody-
namic support was considered an indication to perform a
temporary femorocarotid external shunt. If these criteria were
not met, no carotid bypass shunt was indicated. In this series,
these criteria were not met in all patients in whom the test
was performed no carotid shunt was implanted. The choice of
valve type, balloon valvuloplasty, and post-dilatation was left
to the discretion of the operator.
Clinical End Points and Definitions
The outcomes of interest in this study included periprocedural
and 30-day all-cause mortality, stroke, device success, early
safety, and major outcomes according to the Valve Academic
Research Consortium-2 consensus definitions.14
Statistical Analysis
A continuous propensity score analysis was performed to
adjust for the intergroup clinical differences. A propensity
score representing the likelihood of having a transcarotid
was calculated for each patient by the use of multivariable
logistic regression analysis that identified variables indepen-
dently associated with transcarotid. Continuous variables
were checked for the assumption of linearity in the logit
and the graphical representations suggested linear relation-
ships. Interactions between variables were allowed only if it
was supported clinically and statistically (P<0.20). Variables
retained in the final model were age, hypertension, history
Circ Cardiovasc Interv. 2018;11:e006388. DOI: 10.1161/CIRCINTERVENTIONS.118.006388
of stroke or transient ischemic attack (TIA), history of myocar-
dial infarction, peripheral vascular disease, and the following
2 interaction terms: age and peripheral vascular disease, age
and hypertension. The goodness-of-fit of the model using the
Hosmer-Lemeshow test indicated that the final model was
a good fit (χ2=4.52 with df=8; P=0.81). Matching was then
performed on the propensity score without replacement of
case and control subjects (many to many or complete match-
ing) using the greedy algorithm. A detailed description of the
matching algorithm is available in the Appendix in the Data
Supplement. This complete matching algorithm allows for
maximal use of patients by minimizing exclusion of outliers.
Using this procedure, 94 of 101 transcarotid patients (93.1%)
were matched to 163 transapical/transaortic patients, creat-
ing a series of 58 matched sets with no limitation of the ratio
of transcarotid to control patients. After full matching, statis-
tical analyses used a weighted approach, taking into account
the clustering of patients within each stratum of match. In
addition, a second propensity score model was fit forcing
institution into the model to assess for a potential confound-
ing effect by center. Continuous variables are expressed as
weighted mean±SD and analyzed using the linear regression
model adjusted for stratification (blocking factor). Categorical
variables are expressed using proportions and analyzed with
a linear model and a logit link function adjusted for strati-
fication (blocking factor). Statistical significance was present
when the 2-tailed P value was <0.05. Analyses were per-
formed using SAS, version 9.4 (SAS Institute, Inc, Cary, NC).
RESULTS
Baseline clinical and echocardiographic data compar-
ing unmatched and propensity score-matched transca-
rotid compared with transapical/transaortic patients are
shown in Table 1 (see Appendix in the Data Supplement
for standardized differences). In the unmatched cohorts,
patients in the transcarotid group were slightly older
(mean age, 80.4±8.4 versus 78.2±7.3 years; P=0.02),
with a higher prevalence of peripheral vascular dis-
ease (66.3% versus 47.4%; P=0.002), but comparable
Society of Thoracic Surgeons predicted risk of mortal-
ity (6.6±5.7 versus 6.1±4.4; P=0.32) and EuroSCORE
II (8.7±7.5 versus 8.8±7.3; P=0.91; transcarotid versus
transapical/transaortic, respectively).
Initially, 104 patients had been selected for trans-
carotid access. In 3 of these patients, the transcarotid
approach was abandoned after CCA exposure. Two cases
were because of extensive calcification of the CCA when
assessed by the surgeon on palpation before the punc-
ture, which was not evident on preprocedural imaging.
The other case was because of a low CCA bifurcation
precluding safe access to the vessel. These 3 patients all
underwent successful transaortic TAVR at the same sit-
ting. Therefore, successful vascular access was achieved
in all patients in the transapical/transaortic group and
in 101 (97.1%) patients in the transcarotid group.
Procedural characteristics are summarized in Table  2.
Most patients (89.4%) in the transapical/transaortic
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 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR

Table 1.  Baseline Clinical and Echocardiographic Characteristics of Patients Undergoing TA or TAo Versus TC Transcatheter
Aortic Valve Replacement

Unmatched Data Propensity Score-Matched Data*

TA/TAo TC TA/TAo TC
Variables (n=228) (n=101) P Value (n=163) (n=94) P Value
Age, y 78.2±7.3 80.4±8.4 0.02 79.4±5.4 79.7±8.2 0.57
Women 97 (42.5) 46 (45.5) 0.63 41.1 42.6 0.87
Diabetes mellitus 92 (40.4) 42 (41.6) 0.90 39.2 44.7 0.44
Atrial fibrillation/flutter 75 (32.9) 41 (40.6) 0.21 36.3 42.6 0.38
Hypertension 209 (91.7) 82 (81.2) 0.01 83.1 84.0 0.82
Stroke/TIA 60 (26.3) 16 (15.8) 0.05 16.6 17.0 0.93
Previous myocardial infarction 81 (35.5) 20 (19.8) 0.004 20.5 20.2 0.96
Coronary artery disease 169 (74.1) 64 (63.4) 0.05 75.4 64.9 0.11
Previous CABG 83 (36.4) 24 (23.8) 0.03 32.3 25.5 0.31
Previous pacemaker 41 (18.0) 15 (14.9) 0.53 22.2 16.0 0.26
Peripheral vascular disease 108 (47.4) 67 (66.3) 0.002 68.2 64.9 0.50
Chronic renal failure (eGFR <60 per 125 (54.8) 58 (57.4) 0.72 54.5 58.5 0.58
mL/min)
STS score 6.1±4.4 6.6±5.7 0.32 6.9±3.5 6.2±5.1 0.25
EuroSCORE II 8.8±7.3 8.7±7.5 0.91 9.2±5.3 8.4±6.9 0.29
Echocardiographic parameters
 LV ejection fraction, % 52±14 55±12 0.12 53±10 55±12 0.31
 Mean AV gradient, mm  Hg 38±15 51±13 <0.001 39±12 50±14 <0.0001
 AVA, cm2 0.72±0.27 0.66±0.15 0.05 0.7±0.21 0.67±0.16 0.10
 Moderate-to-severe AR 55 (24.1) 12 (11.9) 0.01 15.8 12.8 0.56

Values are expressed as percentage, n (%), or mean±SD. AR indicates aortic regurgitation; AV, aortic valve; AVA, aortic valve area;
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CABG, coronary artery bypass graft; eGFR, estimated glomerular filtration rate; LV, left ventricle; STS, Society of Thoracic Surgeons; TA,
transapical; TAo, transaortic; TC, transcarotid; and TIA, transient ischemic attack.
*The estimates obtained after propensity score matching are based on the means of a stratified sampling of weighted subjects. More
details are provided in the Appendix in the Data Supplement.

group received the Edwards SAPIEN, SAPIEN XT, or
SAPIEN 3 THV (Edwards Lifesciences, Irvine, CA). In the
transcarotid group, the SAPIEN family of valves was
implanted in 58 patients (57.4%) and the Medtronic
CoreValve and Evolut R THV (Medtronic, Minneapolis,
MN) in 43 patients (42.6%).
After adjustment, there were no significant between-
group differences on access site infection (n=1 in the
transapical approach), cardiac tamponade, and pro-
cedural mortality (0% versus 2.1%; P=0.16; transca-
rotid versus transapical/transaortic, respectively). In
addition, there was no need to implant a second valve
or convert to sternotomy in the transcarotid group.
Postimplantation hemodynamics demonstrated a sig-
nificant reduction in transvalvular aortic mean gradi-
ent and an increase in the effective orifice area in both
groups (Figure).
Postprocedural and 30-day clinical outcomes were
available in all patients surviving the procedure (Table 3).
At 30 days, there were 3 cases (2.9%) of Valve Academic
Research Consortium-2–defined strokes (2 disabling
fatal and 1 nondisabling) in the transcarotid group.
These patients underwent CT or magnetic resonance
imaging and were assessed by a consultant neurologist.
Two strokes were noted in the immediate postoperative
period and 1 on postoperative day 6. This patient had
preoperative atrial fibrillation treated with oral anticoagu-
lation and had a hemorrhagic stroke contralateral to the
transcarotid access site. The other 2 patients had ischemic
strokes ipsilateral to the accessed CCA. However, the risk
of stroke/TIA was not significantly different between
the matched transcarotid versus transapical/transaortic
groups (2.1% versus 3.5%; P=0.67). All patients were
prescribed antiplatelet therapy before the procedure and
received therapeutic intraprocedural heparin.
Compared with transapical/transaortic TAVR,
transcarotid TAVR was also associated with signifi-
cantly less new-onset atrial fibrillation (3.2% versus
19.0%; P=0.002), stage 2 or 3 acute kidney injury
(0% versus 12.1%; P=0.002), major or life-threaten-
ing bleeding (4.3% versus 19.9%; P=0.002), shorter
mean (7.0±6.1 versus 9.9±4.6 days; P=0.0002), and
median (6 versus 8 days; P<0.001) length of hospital
stay (LOS) in matched analyses. Rates of new pace-
maker implantation and myocardial infarction were
comparable between groups, with a tendency toward

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 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR

Table 2.  Procedural and Echocardiographic Characteristics of Patients Undergoing TA or TAo Versus TC Transcatheter Aortic
Valve Replacement

Unmatched Data Propensity Score-Matched Data*

TA/TAo TC TA/TAo TC
Variables (n=228) (n=101) P Value (n=163) (n=94) P Value
Procedural characteristics
 Prosthesis type
  Edwards SAPIEN 42 (18.4) 0 … 18.4 0 …
  SAPIEN XT 144 (63.2) 8 (7.9) … 65.6 8.5 …
  SAPIEN 3 18 (7.9) 50 (49.5) … 9.2 51.1 …
  CoreValve 1 (0.4) 8 (7.9) … 0.6 8.5 …
  Evolut R 3 (1.3) 35 (34.7) … 0 31.9 …
  Other 16 (7) 0 <0.0001 6.1 0 <0.0001
 Preimplant balloon valvuloplasty 174 (84.1) 35 (38.5) <0.0001 83.4 38.1 <0.0001
 Postimplant balloon valvuloplasty 48 (21.1) 4 (4.0) <0.0001 13.7 4.3 0.03
 Access site infection 1 (0.4) 0 1.0 0.2 0 0.71
 Cardiac tamponade 2 (0.9) 1 (1) 1.0 0.5 1.1 0.69
 Need of a second valve 5 (2.2) 0 0.33 1.1 0 0.32
 Conversion to sternotomy 11 (4.8) 0 0.02 4.9 0 0.03
 Procedural mortality 3 (1.3) 0 0.56 2.1 0 0.16
Echocardiography at discharge
 LV ejection fraction, % 51±13 57±10 0.0004 52±9 57±10 0.001
 Mean AV gradient, mm  Hg 11±4 12±7 0.13 10±4 12±6 0.04
 AVA, cm 2
1.45±0.5 1.54±0.45 0.28 1.47±0.26 1.54±0.45 0.36
 Moderate-to-severe AR 9 (4.0) 3 (3.0) 0.76 0.6 2.2 0.88
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Values are expressed as percentage, n (%), or mean±SD. AR indicates aortic regurgitation; AV, aortic valve; AVA, aortic valve area; LV, left
ventricle; TA, transapical; TAo, transaortic; and TC, transcarotid.
*The estimates obtained after propensity score matching are based on the means of a stratified sampling of weighted subjects. More details
are provided in Appendix in the Data Supplement.

less major vascular complications with the transca-
rotid approach (3.2% versus 10.7%; P=0.05). At 30
days, mortality rate in the matched cohort was 2×
higher in the transapical/transaortic compared with
transcarotid group, although this difference did not
reach statistical significance (4.6% versus 2.1%;
P=0.37, respectively).
There was a greater proportion of the newer itera-
tions of THV in the transcarotid group. Therefore, we
reevaluated outcomes after adjusting for prosthesis
type to mitigate a possible confounding effect related
to enhanced features of the newer THV, such as lower
profile delivery systems. The significant salutary effect
of transcarotid access on postprocedural atrial fibrilla-
tion persisted, despite adjusting for THV type. However,
the association between transcarotid access and major
or life-threatening bleeding became nonsignificant, as
was the association between THV type and bleeding.
Taken together, these data suggest that, although THV
type may be partly responsible for the decreased risk
of bleeding associated with transcarotid access, it does
not entirely explain this protective effect (prosthesis-
adjusted analysis, Appendix in the Data Supplement).
No major differences in clinical outcomes were
observed by comparing transapical to transaor-
tic, except for the risk of acute kidney injury that
was higher among transaortic patients (23.2% ver-
sus 11.3%; P=0.03; unadjusted data; Appendix in
the Data Supplement; Tables IV through VI in the
Data Supplement). Institution-specific outcomes for
the entire cohort of transcarotid patients were also
compared, and no major differences were observed
(Appendix in the Data Supplement; Table VII in the Data
Supplement). When institution was forced into the pro-
pensity score model to adjust for a potential confound-
ing effect by center, we obtained similar results to the
main analysis (Appendix in the Data Supplement; Table
VIII in the Data Supplement).
DISCUSSION
This is the first report of a multicenter propensity score-
matched comparison between transcarotid and trans-
thoracic access. The main findings are (1) transcarotid
TAVR is safe and feasible in appropriately selected
patients with a high rate of device success (87%); (2)

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 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR

Figure. Changes in mean aortic gradient and effective orifice area between baseline and discharge.
A, Mean aortic gradient; (B) effective orifice area. TA-TAO indicates transapical-transaortic; and TC, transcarotid.

compared with transapical and transaortic TAVR, the
transcarotid approach was associated with no signifi-
cant difference in rates of 30-day all-cause mortality,
stroke, new pacemaker implantation, major vascular
complications, and hemodynamic performance; (3)
transcarotid TAVR is associated with significantly less
new-onset atrial fibrillation, acute kidney injury, major
or life-threatening bleeding, and shorter hospital stay.
TAVR technology has evolved considerably in the last
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Despite their advantage of simplifying valve position-
ing, major surgical manipulation of the chest wall is
required. Furthermore, these techniques are limited by
relative contraindications, such as significant respira-
tory failure in case of transapical, and porcelain aorta,
as well as previous heart surgery, in cases of transaor-
tic. Transcarotid TAVR was first performed in France in
2009,20 and then was subsequently adopted by several
other centers.7–9,21,22 These experiences demonstrated

few years allowing for the treatment of 85% to 90% of
patients via the transfemoral route.4,15,16 Until recently,
the transapical and transaortic approaches were con-
sidered the main alternative nontransfemoral routes,
with comparable short- and long-term outcomes.17–19
that the surgical approach to the carotid artery is safe
and relatively uncomplicated because of its superficial
location, and operative experience with the carotid
arteries is widespread among cardiovascular surgeons.
We prefer performing transcarotid TAVR using the left

Table 3.  Clinical Outcomes at 30 Days of Patients Undergoing TA or TAo Versus TC Transcatheter Aortic Valve Replacement

Unmatched Data Propensity Score-Matched Data*

TA/TAo TC TA/TAo TC
Outcomes (n=228) (n=101) P Value (n=163) (n=94) P Value
Mortality 14 (6.1) 5 (5.0) 0.80 4.6 2.1 0.37
Stroke/TIA 11 (4.8) 3 (2.9) 0.56 3.5 2.1 0.67
New pacemaker implantation 25 (10.9) 7 (6.9) 0.23 13.2 8.8 0.34
New-onset atrial fibrillation 52 (22.8) 4 (4.0) <0.0001 19.0 3.2 0.002
Myocardial infarction 6 (2.6) 1 (1.0) 0.68 4.4 1.1 0.19
Major or life-threatening bleeding 32 (14.0) 4 (4.0) 0.01 19.9 4.3 0.002
Major vascular complication 16 (7.0) 3 (3.0) 0.20 10.7 3.2 0.05
Acute kidney injury (stage 2–3) 34 (14.9) 0 <0.0001 12.1 0 0.002
Median LOS, d 8 (6–11) 6 (3–8) <0.001 8 (6–12) 6 (3–8) <0.001
Composite end points
 Device success 197 (86.8) 86 (86.9) 1.0 89.8 89.1 0.75
 Early safety 161 (70.6) 93 (92.1) <0.0001 71.7 92.6 0.002

Values are expressed as percentage, n (%), or mean ±SD. LOS indicates length of stay; TA, transapical; TAo, transaortic; TC, transcarotid;
and TIA, transient ischemic attack.
*The estimates obtained after propensity score matching are based on the means of a stratified sampling of weighted subjects. More
details are provided in Appendix in the Data Supplement.

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 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR
common carotid because it allows superior coaxial
alignment of the THV with the aortic annulus, although
both sides can be used.9,10,21
In the current study, the 30-day crude stroke or TIA
rate in the transcarotid group was 3% (2 disabling and
1 nondisabling stroke), with no significant difference
compared with the transapical/transaortic group (as
previously described in smaller studies).10,11 This stroke
rate is lower than that observed in the cohort of patients
included in the multicenter French Transcarotid TAVR
Registry and others.8,9 As previously described,8,21 these
neurological events are not always localized ipsilateral
to the CCA used for TAVR. This suggests that there are
other phenomena at play in addition to carotid arterial
manipulation, such as new-onset postprocedural atrial
fibrillation, periprocedural hypotension, inadequate
contralateral carotid perfusion, and the THV deploy-
ment itself. Although the rates of preimplant and post-
implant balloon valvuloplasty were significantly higher
in the transapical/transaortic group even after adjust-
ment, this did not translate to a higher risk of stroke
or TIA among the transapical/transaortic patients. The
low rate of stroke observed in this study may be attrib-
uted to careful patient selection and the intraoperative
assessment of the functional integrity of the circle of
Willis as used in one center in this study, using indi-
rect methods, such as backflow blood pressure during
carotid clamping and cerebral oximetry monitoring.7
However, the optimal preprocedural evaluation and
Downloaded from http://ahajournals.org by on July 2, 2019
periprocedural neurological monitoring during transca-
rotid TAVR are yet to be determined. Also, the optimal
antithrombotic regimen and the role of embolic pro-
tection devices23–25 require further study to determine
efficacy in the reduction of the risk of cerebral ischemia,
specifically in patients undergoing transcarotid TAVR as
literature is scarce in these patients.
Other major findings of this study were that trans-
carotid TAVR was significantly associated with a reduc-
tion in major or life-threatening bleeding and shorter
LOS, compared with transapical/transaortic TAVR. This
could be explained by (1) less-invasive access site expo-
sure in the case of transcarotid TAVR compared with
a minithoracotomy or hemisternotomy in the trans-
apical/transaortic approach; (2) less ventilator use and
shorter intensive care unit stay in transcarotid TAVR10;
and (3) less pain during the postprocedural recovery
and earlier patient mobilization. The lower incidence of
new-onset atrial fibrillation among transcarotid TAVR
patients may also partly explain shorter LOS. Any inci-
sion of the thoracic cavity is associated with various
forms of supraventricular arrhythmia, most commonly
atrial fibrillation, which may then translate to a pro-
longed hospital stay.26,27 A reduction of LOS is a critical
component of current strategies to control overall costs
associated with TAVR and may be the primary driver
of reduced expenditure associated with transfemoral
Circ Cardiovasc Interv. 2018;11:e006388. DOI: 10.1161/CIRCINTERVENTIONS.118.006388
TAVR compared with alternative-access TAVR.28–30
Furthermore, severe bleeding may be associated with
postprocedural hypovolemia and may explain, in part,
the reduction in the rates of severe acute kidney injury
in transcarotid cases compared with the transapical/
transaortic approach.31,32 Similar findings were previ-
ously reported when comparing transapical or transaor-
tic with transfemoral access. Blackstone et al33 reported
their results in 501 propensity score-matched patients
undergoing transapical versus transfemoral TAVR. More
patients in the transapical group experienced adverse
procedural events, longer length of stay, slower recov-
ery, and higher transfusion rates. Similar results were
published by Arai et al,34 who reported significantly
higher rates of life-threatening bleeding when compar-
ing transaortic (n=289) with transfemoral TAVR (n=467;
6% versus 3%, respectively; P=0.021) without a signifi-
cant difference in other major outcomes. Our data also
suggest that the risk of major vascular complications are
decreased with a transcarotid TAVR approach (matched
analysis, 3.2% versus 10.7%; P=0.05), although the
study was underpowered for this specific end point and
did not reach statistical significance.
Postoperative echocardiographic data showed
favorable results in both groups, as either access pro-
vides direct aortic annular access and may allow supe-
rior positioning in particular anatomies (Figure). The
observed 30-day mortality in the adjusted analysis
(2.1% versus 4.6%; P=0.37; transcarotid versus trans-
apical/transaortic, respectively) was also statistically
comparable between groups and lower than that previ-
ously reported in transcarotid TAVR cohorts.8,9
Study Limitations
This report consists of a retrospective analysis of pro-
spectively acquired data and is subject to the limita-
tions inherent in this study design. Selection of patients
was not random and may not be generalizable to other
centers. Other alternative approaches, such as the
subclavian route, were not evaluated because of the
limited number of patients undergoing TAVR by sub-
clavian access at the participating centers. The super-
ficial position of the carotid artery coupled with the
more complex exposure of the subclavian and its prox-
imity to the brachial plexus, and the risks associated
with its use if an ipsilateral internal mammary artery
was used as a coronary bypass graft, have lead us to
favor transcarotid over the subclavian approach. As
well, specific end points, such as mortality, stroke, and
major vascular complications, may have not reached
statistical significance because of the small sample
size and short-term follow-up. However, this is the
largest multicenter study evaluating the transcarotid
approach using a risk-adjusted comparator arm. Small
numbers did not permit us to ascertain device-specific
November 2018 7
 Chamandi et al; Comparison of Transcarotid vs Transthoracic TAVR
outcomes. However, adjusting the analysis for type of
THV, we found that the association between decreased
major bleeding and the transcarotid approach was
modulated, in part, by the use of newer valve types
with their lower profile delivery systems but was not
entirely explained by this feature of the newer THVs
(Appendix in the Data Supplement). Taken further,
this association may also be access site specific and
not entirely device specific. Accessing proximal high-
pressure structures, such the left ventricular apex and
ascending aorta, may be associated with less ability to
adequately control bleeding compared with distal arte-
rial sites, such as the carotid artery. Device-specific fea-
tures of the newer TAVR prostheses, such as improved
sealing skirts, did not influence postprocedural aortic
regurgitation, need for a permanent pacemaker, pres-
sure gradients, and overall procedural success rates in
our study, which were similar between the transcarotid
and transapical/transaortic groups.
Periprocedural cerebral monitoring was variable
among institutions during transcarotid TAVR, reflecting a
lack of consensus in the literature, and the rates of neu-
rological events may have been underestimated because
systematic evaluation by magnetic resonance imaging
was not routinely performed following TAVR. However,
the incidence of stroke/TIA was low and did not dif-
fer among centers (Table VII in the Data Supplement);
the optimal perioperative neuromonitoring technique
Downloaded from http://ahajournals.org by on July 2, 2019
remains to be prospectively elucidated. However, all clin-
ically significant neurological changes were identified,
and all sites had a low-threshold trigger for consultation
by a neurologist and the performance of neuroimaging
post-TAVR. Preprocedural and postprocedural antiplate-
let and anticoagulation therapy were not consistently
captured across the study centers, which may confound
the association between the approaches studied and
outcomes, such as bleeding, cerebrovascular events,
and mortality. However, all centers stopped the second
antiplatelet agent at least 48 hours before the proce-
dure for patients undergoing transapical or transaortic
TAVR. We, therefore, cannot attribute the increased
bleeding rates associated with transapical/transaortic
solely to preoperative double antiplatelet therapy.
Conclusions
Transcarotid vascular access for TAVR is safe, feasible,
and associated with encouraging short-term clinical
outcomes in terms of mortality, stroke, and major vas-
cular complications in patients who are not candidates
to transfemoral TAVR. Furthermore, the transcarotid
approach was associated with lower rates of major or
life-threatening bleeding, new-onset atrial fibrillation,
acute kidney injury, and shorter LOS compared with
transapical or transaortic access. Larger prospective
studies with longer follow-up are needed to confirm
Circ Cardiovasc Interv. 2018;11:e006388. DOI: 10.1161/CIRCINTERVENTIONS.118.006388
the safety and clinical efficacy of transcarotid TAVR
compared with alternative approaches.
ARTICLE INFORMATION
Received January 3, 2018; accepted September 22, 2018.
The Data Supplement is available at https://www.ahajournals.org/doi/
suppl/10.1161/CIRCINTERVENTIONS.118.006388.
Correspondence
Siamak Mohammadi, MD, FRCSC, Division of Cardiac Surgery, Quebec Heart
and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec,
Canada. Email siamak.mohammadi@fmed.ulaval.ca
Affiliations
Department of Cardiac Surgery and Cardiology, Quebec Heart and Lung Institute,
Laval University, Canada (C.C., J.R.-C., E.D., D.D., R.D., J.-M.P., R.P., F.M., T.R.-G.,
D.K., S.M.). Department of Cardiac Surgery and Cardiology, Hôpital Européen
Georges Pompidou, Assistance Publique Hôpitaux de Paris, Université Paris
Descartes, France (R.A.-A., D.B., C.S., J.-Y.P., A.L., N.K.). Department of Cardiac
Surgery and Cardiology, Clinique St Gatien, Tours, France (D.B., S.C., O.L.P.).
Acknowledgments
We thank Stéphanie Dionne, Serge Simard, and Mélanie Côté from the Quebec
Heart and Lung Institute, for their help in the statistical analysis.
Disclosures
Dr Chamandi has received a fellowship grant from Edwards Lifesciences. Dr
Rodés-Cabau has received research grants from Edwards Lifesciences and
Medtronic. The other authors report no conflicts.
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