Alternate accesses for transcatheter aortic valve replacement: A network meta-analysis

Background: When transfemoral (TF) access is contraindicated in patients undergoing transcatheter aortic valve replacement (TAVR), alternate access strategies are considered. The choice of one alternate access over the other remains controversial. Methods: Following a comprehensive literature search, studies comparing any combination of TF, transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) TAVR were identified. Data were pooled using fixed- and random-effects network meta-analysis. Rank scores with probability ranks of different treatment groups were calculated. Results: Eighty-four studies (26,449 patients) were included. Compared to TF access, TA and TAo accesses were associated with higher 30-day mortality (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.31–1.94; OR 1.79, 95% CI 1.21–2.66, respectively), while the TC and TS showed no difference (OR 1.12, 95% CI 0.64–1.95; OR 1.23, 95% CI 0.67–2.27, respectively); TF access ranked best followed by TC. There was no significant difference in 30-day stroke; TC access ranked best followed by TS. At a weighted mean follow-up of 1.6 years, TA and TAo accesses were associated with higher long-term mortality versus TF (incidence rate ratio [IRR] 1.31, 95% CI 1.18–1.45; IRR 1.41, 95% CI 1.11–1.79, respectively); there was no difference between TC and TS versus TF access (IRR 1.02, 95% CI 0.70–1.47; IRR 1.16, 95% CI 0.82–1.66, respectively); TF access ranked best followed by TC. At a weighted mean follow-up of 1.4 years, only TA access was associated with higher long-term stroke compared to TF (IRR 3.01, 95% CI 1.15–7.87); TF access ranked as the best strategy followed by TAo. Conclusion: TC and TS approaches are associated with superior postoperative outcomes compared to other TAVR alternate access strategies. Randomized trials definitively assessing the safety and efficacy of alternate access strategies are needed.