title: Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients: initial human experience.
abstract: OBJECTIVE
  This study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava.
  
  
  BACKGROUND
  TAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals.
  
  
  METHODS
  We performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access.
  
  
  RESULTS
  Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract.
  
  
  CONCLUSIONS
  Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.
authors.affiliation: Institute for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan. Electronic address: agreenb1@hfhs.org.
authors.forename: Adam B
authors.initials: AB
authors.lastname: Greenbaum
authors.affiliation: Institute for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: William W
authors.initials: WW
authors.lastname: O'Neill
authors.affiliation: Division of Cardiac Surgery, Henry Ford Health System, Detroit, Michigan.
authors.forename: Gaetano
authors.initials: G
authors.lastname: Paone
authors.affiliation: Institute for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Mayra E
authors.initials: ME
authors.lastname: Guerrero
authors.affiliation: Institute for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Janet F
authors.initials: JF
authors.lastname: Wyman
authors.affiliation: Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: R Lebron
authors.initials: RL
authors.lastname: Cooper
authors.affiliation: Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Lederman
mesh_terms: D000369:Aged, 80 and over; D000792:Angiography; D001013:Aorta, Thoracic; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods*; D005260:Female; D005471:Fluoroscopy; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014684:Venae Cavae
keywords: caval-aortic; extra-anatomic procedures; transcatheter aortic valve replacement; transcaval