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

2. Christian Shults, MD
I have no relevant financial relationships

3. Trans-femoral Alternative Access Trans-axillary
Trans-caval / Trans-aortic
Trans-apical
Trans-Carotid

4. Staying out of the chest
Intrathoracic access associated with:
increased length of stay
increased cost
slower recovery
increased 30 day and 1 year mortality.

5. Patients Selected for TransCarotid 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

6. 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

7. Intra-op Cerebral Oximetry EEG monitoring SBP > 100mmHg
(Near infrared spectrometry)
EEG monitoring
SBP > 100mmHg
General vs. Awake
Awake - test clamping for 3 minutes
Symptomatic
Femoro-carotid shunt

8. Transcarotid TAVR Concept Cerebral Bypass Circuit
SHUNT
SHEATH

9. Transcarotid TAVR

10. Transcarotid TAVR

11. Transcarotid TAVR

13. Transcarotid TAVR Easy Access Hemodynamically Tolerated
Good Control with Deployment
Minimal Blood Loss
Easy Repair (Patch or Direct)

14. Transcarotid TAVR

15. Emory Transcarotid TAVR Experience
30- day outcomes
N=14
Success
100%
30 day Mortality
Bleeding
Vascular Complications
Renal Failure
PVL > Grade 1
Clinical Stroke

16. 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

17. 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.

18. Follow up
Doppler imaging of carotid prior to discharge

19. 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