Suprasternal Access for Transcatheter Aortic Valve Replacement for Self-Expanding Valves: A Simple Reliable Alternative Access A
mediaposted on 04.05.2021, 17:51 by Kyle W. Eudailey
Background: Transcatheter aortic valve replacement (TAVR) has proven be an effective and safe option for intermediate and high surgical risk patients.  Despite the continued advancement of valve technology and delivery systems, there still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach.  Several options for alternative access for TAVR have been described in the literature, including transcaval, axillary, subclavian, transcarotid, and suprasternal. [2-7] We have found suprasternal TAVR (SS-TAVR) as a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route.
Preoperative Evaluation and Planning:
Patient Selection: -
Reserved for patients in whom TF access is not feasible (small size, toruosity, calcium) - Also used for patients deemed high risk for vascular complications (abdominal or thoracic pathology or atheroma, or morbid obesity) - Preoperative computerized tomography (CT) is paramount for planning
SS-TAVR Candidates are evaluated based on 4 criteria: 1.) an innominate artery with an area free of calcium for sheath insertion 2.) a minimum diameter of the innominate artery of 7 mm 3.) limited angulation or tortuosity of the innominate artery and its attachment to the transverse arch 4.) a minimum distance of 7-8 cm from the expected site of sheath insertion to the aortic annulus - No strict contraindications (prior cardiac surgery, neck surgery, tracheostomy, carotid endarterectomy, mediastinal radiation all okay) - Relative Contraindications: deformity of cervical spine which limits neck extension, large thyroid mass.
Patient Positioning and OR Setup -
General anesthesia and TEE required - Bilateral non invasive cerebral saturation monitors - Cephalad on OR table, supine, shoulder roll, maximal neck extension - Right internal jugular vein vs femoral venous temporary pacer, right radial arterial line - C-arm left side - Left radial flush catheter - Operator 1 right side, assistant left side, Operator 2 to the right of the Operator 1
Surgical Technique -
3cm curvilinear incision similar to mediastinoscopy approach - Platysma divided, dissection between sterno-thyroid muscles to pretracheal fascia. - Inominate identified by palpation - Division of right sterno-thyroid muscle - Vessel loop is used to improved exposure and bring artery into operative field - Two 4-0 prolene purse-strings-> artery punctured under direct visualization
TAVR Technique -
7F sheath placed and flushed carefully - Valve crossed using AL-1 catheter and straight wire - Straight wire exchanged for a J wire and AL-1 exchanged for a pigtail - Single Curved Lunderquist seated in apex - Single dilation performed-> valve delivery system advanced - Deployment of Evolut in standard fashion - Minimal stored energy in the system, valve system tends ventricular on the Non-Coronary
Careful hemostasis following removal of system - Check cerebral saturations and ensure they are baseline