Transcarotid Transcatheter Aortic Valve Replacement

In the United States, transcatheter aortic valve replacement (TAVR) has become a common treatment strategy in patients with aortic stenosis who have an estimated moderate-to-high STS risk of mortality if undergoing surgical aortic valve replacement. With advanced age and multiple comorbidities, only around 80% to 90% of these patients are candidates for a transfemoral access approach. The next most common approaches are subclavian and direct aortic, but for patients with severe peripheral artery disease with calcified ascending aorta, a second alternative access is needed. The authors present their technique for implanting a TAVR valve using the right carotid approach.

This video demonstrates the exposure and insertion of the 14 Fr delivery sheath. Tips for successful delivery include:

1. Expose the common carotid artery at least 3 - 4 cm to allow proximal and distal control.
2. Use neurological monitoring (electroencephalogram, transcranial doppler, cerebral oximetry, etc).
3. Before insertion of 14 Fr sheath, clamp the distal common carotid artery and ensure that there is no change on the neurological monitor. Keep the artery clamped during delivery to prevent embolism.
4. The artery 14 - 16 Fr sheath can be trimmed (10 - 15 cm shorter) in order to facilitate loading of the valve in the ascending aorta.
5. Extend the arteriotomy over the wire transversely to allow sheath entry without injury to vessel.
6. After delivery of the valve and removal of the sheath, flush the artery proximally and distally in a similar fashion of any carotid repair.
7. No drain is usually necessary unless the patient is anticoagulated or has bleeding diathesis.

Suggested Reading

1. Azmoun A, Amabile N, Ramadan, R, et al. Transcatheter aortic valve implantation through carotid artery access under local anaesthesia. Eur J Cardiothorac Surg. 2014;46(4):693-698. 
2. Kallinikou Z, Berger A, Ruchat P, et al. Transcutaneous aortic valve implantation using the carotid artery access: feasibility and clinical outcomes. Arch Cardiovasc Dis. 2017;110(6-7):389-394. 
3. Stonier T, Harrison M, Choong AM. A systematic review of transcatheter aortic valve implantation via carotid artery access. Int J Cardiol. 2016;219:41-55.