title: Trans-subclavian versus transapical access for transcatheter aortic valve implantation: A multicenter study.
abstract: OBJECTIVE
  To compare the outcomes of trans-subclavian (TS) and transapical (TA) access for transcatheter aortic valve implantation (TAVI).
  
  
  BACKGROUND
  A considerable proportion of patients undergoing TAVI are not eligible for transfemoral approach. To date, there are few data to guide the choice between alternative vascular access routes.
  
  
  METHODS
  Among 874 consecutive patients who underwent TAVI, 202 procedures were performed through TA (n = 142, 70.3%) or TS (n = 60, 29.7%) access. Medtronic Corevalve (CV, Medtronic, Minneapolis, MN) was implanted in 17.3% of the patients, the Edwards-Sapien (ES, Edwards Lifesciences Inc., Irvine, CA) in 81.2% and other prostheses in 0.1%. In-hospital and long-term outcome were assessed using the Valve Academic Research Consortium (VARC)-2 definitions.
  
  
  RESULTS
  Mean age was 82 ± 6 years, STS score 9.3 ± 7.9%. The 2 groups showed a relevant imbalance in baseline characteristics. In hospital mortality was 6.4% (1.7% TS vs. 8.4% TA, P = 0.06), stroke 2.0%, acute myocardial infarction 1.0%, acute kidney injury 39.4%, sepsis 4.0% with no significant differences between groups, while bleeding was more frequent in TA patients (53.5% vs. 11.7% TS, P < 0.001). One- and 2-year survival was 85.2% and 73.2% in TS patients, and 83.9% and 74.9% in TA patients (P = ns for both). Access site was not an independent predictor of mortality at multivariable analysis.
  
  
  CONCLUSIONS
  Transapical compared with trans-subclavian access for TAVI was associated with a nonsignificant trend to increased periprocedural events. However, 1- and 2-year survival appears similar.
authors.affiliation: Cardiovascular Department, Institute of Cardiology, University of Bologna, Policlinico S, Orsola-Malpighi, Bologna, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Ciuca
authors.affiliation: Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Tarantini
authors.affiliation: Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.|Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.affiliation: Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Gasparetto
authors.affiliation: Department of Cardiac Surgery, University of Bologna, Bologna, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Savini
authors.affiliation: Department of Cardiac Surgery, University of Bologna, Bologna, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Di Eusanio
authors.affiliation: Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Napodano
authors.affiliation: Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.affiliation: Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.
authors.forename: Gino
authors.initials: G
authors.lastname: Gerosa
authors.affiliation: Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.|Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Sticchi
authors.affiliation: Cardiovascular Department, Institute of Cardiology, University of Bologna, Policlinico S, Orsola-Malpighi, Bologna, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Marzocchi
authors.affiliation: Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy.
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
authors.affiliation: Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.|Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.affiliation: Cardiovascular Department, Institute of Cardiology, University of Bologna, Policlinico S, Orsola-Malpighi, Bologna, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Saia
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods*; D016009:Chi-Square Distribution; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D012307:Risk Factors; D013348:Subclavian Artery; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic stenosis; outcome; transcatheter aortic valve replacement; vascular access