title: Transcatheter aortic valve implantation through carotid artery access under local anaesthesia.
abstract: OBJECTIVE
  Trans-femoral and transapical are the most commonly used accesses for transcatheter aortic valve implantation (TAVI). However, when these approaches are unsuitable, alternative accesses are needed. We report a series of 19 patients undergoing TAVI through common carotid artery (CCA) access under local anaesthesia in order to assess its feasibility and safety.
  
  
  METHODS
  From November 2008 to September 2013, 361 patients underwent TAVI at our institution. Nineteen of them (14 men) with mean age 82.2 ± 6.2 years, EuroSCORE 25.2 ± 15.7, Society of Thoracic Surgeons score 11.9 ± 5.1 and with severe peripheral arteriopathy were unsuitable for usual approaches and underwent TAVI through CCA access under local anaesthesia. Preoperative computed tomography assessed suitable carotid artery anatomy. Common carotid cross-clamping test allowed verifying patient's neurological status stability. An 18-Fr or 20-Fr sheath inserted into the CCA down into the ascending aorta was used for the delivery catheter. Valve implantation procedures were as usual. After sheath removal, the CCA was surgically purged and repaired. Feasibility and safety end points (VARC-2) were collected up to 30 days.
  
  
  RESULTS
  Transcarotid insertion of the delivery sheath was successful in all cases (8 right, 11 left) and accurate deployment of the device was achieved in 18 patients (4 Edwards SAPIEN XT and 14 Medtronic CoreValve). There was 1 intraoperative death by annulus rupture during preimplant balloon valvuloplasty, and 1 in-hospital death due to multisystem organ failure. There was no myocardial infarction, stroke or major bleeding. Third-degree atrioventricular block requiring pacemaker implantation occurred in 3 patients. No vascular access-site, access-related or other TAVI-related complication occurred. Echocardiography revealed good prosthesis functioning with none, mild and moderate paravalvular leak in, respectively, 8, 9 and 1 patients. Patient ambulation was immediate after TAVI and hospital stay was 4.6 ± 2.3 days.
  
  
  CONCLUSIONS
  TAVI through the CCA approach under local anaesthesia is feasible and safe. It allows continuous clinical neurological status monitoring with low risk of stroke, bleeding events, vascular access-site and access-related complications and immediate patient ambulation. It appears to be a valuable alternative access for patients who cannot undergo trans-femoral TAVI.
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France azmoun@yahoo.com.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Azmoun
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Amabile
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Ramzi
authors.initials: R
authors.lastname: Ramadan
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Saïd
authors.initials: S
authors.lastname: Ghostine
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Caussin
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Sahbi
authors.initials: S
authors.lastname: Fradi
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: François
authors.initials: F
authors.lastname: Raoux
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Brenot
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Remi
authors.initials: R
authors.lastname: Nottin
authors.affiliation: Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Deleuze
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local / Q000009:adverse effects / Q000379:methods*; D001024:Aortic Valve Stenosis / Q000601:surgery; D017536:Carotid Artery, Common / Q000601:surgery*; D015331:Cohort Studies; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000379:methods*
keywords: Local anaesthesia; Transcarotid access; Transcatheter aortic valve implantation