Vascular access in patients with peripheral arterial disease undergoing TAVI: the hostile registry

BACKGROUND The optimal access route in patients with severe peripheral artery disease (PAD) undergoing TAVI remains undetermined. OBJECTIVE To compare clinical outcomes with transfemoral access (TFA), transthoracic access (TTA), and non-thoracic alternative access (TAA) in TAVI patients with severe PAD. METHODS Patients with PAD and hostile femoral access (TFA impossible, or possible only after percutaneous treatment) undergoing TAVI at 28 international centers were included in this registry. The primary endpoint was the propensity-adjusted risk of 30-day major adverse events (MAE) defined as the composite of all-cause mortality, stroke/transitory ischemic attack (TIA) or main access site-related VARC 3 major vascular complications. Outcomes were also stratified according to the severity of PAD using a novel risk score (Hostile score). RESULTS Among the 1,707 patients included in the registry, 518 (30.3%) underwent TAVI with TFA after percutaneous treatment, 642 (37.6%) with TTA, and 547 (32.0%) with TAA (mostly transaxillary). Compared with TTA, both TFA (adjusted HR=0.58, 95%CI 0.45-0.75) and TAA (adjusted HR=0.60, 95%CI 0.47-0.78) were associated with lower 30-day rates of MAE, driven by fewer access site-related complications. Composite risks at 1 year were also lower with TFA and TAA compared with TTA. TFA compared with TAA was associated with lower 1-year risks of stroke/TIA (adjusted HR=0.49, 95%CI 0.24-0.98), a finding confined to patients with low Hostile scores (Pinteraction=0.049). CONCLUSIONS Among patients with PAD undergoing TAVI, both TFA and TAA were associated with lower 30-day and 1-year rates of MAE compared with TTA, but 1-year stroke/TIA rates were higher with TAA compared with TFA.