Comparison of Transfemoral versus Transsubclavian/Transaxillary access for transcatheter aortic valve replacement: A systematic review and meta-analysis

Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Safe alternative access, that represents about 15 % of TAVR cases, remains important for patients without adequate transfemoral access. We aimed to perform a systematic review and meta-analysis of studies comparing transfemoral (TF) access versus transsubclavian or transaxillary (TSc/TAx) access in patients undergoing TAVR. We searched PubMed, Cochrane CENTRAL Register, EMBASE, Web of Science, Google Scholar and ClinicalTrials.gov (inception through May 24, 2022) for studies comparing (TF) to (TSc/TAx) access for TAVR. A total of 21 studies with 75,995 unique patients who underwent TAVR (73,203 transfemoral and 2,792 TSc/TAx) were included in the analysis. There was no difference in the risk of in-hospital and 30-day all-cause mortality between the two groups (RR 0.64, 95 % CI 0.36-1.13, P = 0.12) and (RR 0.95, 95 % CI 0.64-1.41, P = 0.81), while 1-year mortality was significantly lower in the TF TAVR group (RR 0.79, 95 % CI 0.67-0.93, P = 0.005). No significant differences in major bleeding (RR 0.82, 95 % CI 0.65-1.03, P = 0.09), major vascular complications (RR 1.14, 95 % CI 0.75-1.72, P = 0.53), and stroke (RR 0.66, 95 % CI 0.42-1.02, P = 0.06) were observed. In patients undergoing TAVR, TF access is associated with significantly lower 1-year mortality compared to TSc/TAx access without differences in major bleeding, major vascular complications and stroke. While TF is the preferred approach for TAVR, TSc/TAx is a safe alternative approach. Future studies should confirm these findings, preferably in a randomized setting.