Transcatheter aortic valve replacement (TAVR) has several alternative access routes when transfemoral access is unsuitable. This study compared perioperative and mid-term outcomes of transaxillary (TAx) TAVR with those of transapical (TA) and direct aortic (DA) approaches. Among 2,185 patients who underwent TAVR at our three centers between April 2015 and April 2024, 198 non-transfemoral cases were retrospectively analyzed. TAx-TAVR was classified as a non-thoracotomy approach, whereas TA/DA-TAVR were classified as thoracotomy approaches. Perioperative and mid-term outcomes were compared between the two groups. Of the 198 patients, 97 underwent the non-thoracotomy approach and 101 underwent thoracotomy (TA, n = 64; DA, n = 37). Most baseline characteristics were comparable, although dialysis-dependent patients were more common in the non-thoracotomy group. Operative time, transfusion requirement, and hospital stay were significantly greater in the thoracotomy group. Access-related complications included four events in the thoracotomy group (aortic injury or apical rupture) and five events in the non-thoracotomy group (aortic dissection or intimal injury). Postoperative ischemic stroke tended to occur more frequently in the non-thoracotomy group, though not significantly. One-year survival was significantly higher in the non-thoracotomy group, whereas mid-term mortality did not differ between groups. TAx-TAVR was associated with lower perioperative invasiveness and superior one-year survival compared with TA/DA-TAVR. However, the trend toward increased postoperative stroke underscores the importance of careful patient selection and thorough preoperative vascular assessment.
BACKGROUND:The poor prognosis of hemodialysis (HD) patients following transcatheter aortic valve replacement (TAVR) has been established; however, data on the outcomes in the latest generation of devices remain inconsistent. OBJECTIVES:The authors aimed to compare the 1-year clinical outcomes post-TAVR using the latest generation of devices in HD and non-HD patients. METHODS:From the multicenter registry, 760 HD and 3,928 non-HD patients were identified from the OCEAN-TAVI (Optimized transCathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation; UMINID:000020423) registry. To minimize differences in baseline characteristics, 1:1 propensity score matching (PSM) was performed (490 patients each). The primary clinical endpoint was all-cause mortality at 1 year. Secondary endpoints included cardiovascular death, stroke, and heart failure rehospitalization. RESULTS:In the overall cohort, during 208 (41-373) days of follow-up, HD patients had higher 1-year mortality than non-HD patients (105 of 760 [13.8%] vs 189 of 3,928 [4.8%], HR: 2.62; 95% CI: 2.13-3.23; P < 0.001); this difference was attenuated (59 of 490 [12.0%] vs 65 of 490 [13.3%], HR: 1.03; 95% CI: 0.75-1.42; P = 0.858) following well-balanced PSM. There were no significant differences in any secondary endpoints between the 2 groups after PSM; however, HD remained an independent predictor of 1-year mortality in a multivariate analysis of the cohort before PSM. CONCLUSIONS:The poor prognostic value of HD was attenuated after adjusting for baseline risk factors. These findings suggest that the poor outcomes of HD patients result from the burden of multiple comorbidities in addition to the HD risk itself. Considering TAVR as a treatment option for exceptionally high-risk populations will aid in the careful patient selection and realistic prognostic assessments.
Background Whether atherectomy-assisted drug-coated balloon (DCB) therapy provides durable benefit in severely calcified femoropopliteal (FP) lesions remains uncertain. Objectives In this study, we wanted to compare clinical outcomes of rotational atherectomy plus DCB vs DCB alone in severely calcified FP lesions. Methods In this multicenter retrospective study, 582 de novo FP lesions with Peripheral Arterial Calcium Scoring System grades 3 to 4 were evaluated. After propensity score matching, 153 lesion pairs treated with DCB alone or rotational atherectomy plus DCB were analyzed. The primary endpoint was 2-year primary patency. Hierarchical Cox models adjusted for baseline, procedural, and acute angiographic factors. Results The median follow-up duration was 439 days (IQR: 232-760). Rotational atherectomy use resulted in significantly lower postprocedural residual stenosis (16.7% [95% CI: 14.9-18.4] vs 20.3% [95% CI: 17.8-22.9]; P = 0.019) and fewer lesions with residual stenosis >30% (9/153 lesions, 5.9% [95% CI: 3.1-10.8] vs 22/153 lesions, 14.4% [95% CI: 9.7-20.8]; P = 0.012). One-year primary patency was higher in the rotational atherectomy group (86.2% [95% CI: 80.0-92.3] vs 75.1% [95% CI: 67.8-82.4]; P = 0.01), but this difference attenuated at 2 years (64.4% [95% CI: 52.4-76.4] vs 57.1% [95% CI: 47.1-65.9]; P = 0.07). In hierarchical Cox models, rotational atherectomy use remained independently associated with improved patency after adjusting for acute angiographic results (HR: 0.56; 95% CI: 0.31-1.00; P = 0.05). Procedural complications were markedly higher with rotational atherectomy, driven by distal embolization. Conclusions Although rotational atherectomy improves acute luminal results, the early patency benefit is not durable and is offset by increased procedural risk, supporting selective rather than routine use.
OBJECTIVE:In patients with chronic limb threatening ischaemia (CLTI), pedal artery angioplasty (PAA) is widely known to improve wound healing, but inframalleolar revascularisation may worsen arterial lesion morphology and lead to wound recurrence after healing. This retrospective cohort study aimed to clarify the effects of PAA on wound recurrence after wound healing. METHODS:Consecutive limbs with CLTI (n = 534) secondary to infrapopliteal and pedal artery disease that underwent endovascular therapy (EVT) and achieved complete wound healing at eight cardiovascular centres in Japan were analysed (March 2021 - December 2023). Limbs were divided into two groups according to whether PAA was performed (n = 89) or not (n = 445). RESULTS:Propensity score matching extracted 160 matched limbs that had no remarkable intergroup differences in patient and lesion characteristics. The wound recurrence rate at one year was statistically significantly higher in the PAA group than in the non-PAA group (51.4% vs. 23.5%; p < .001). Low serum albumin level, haemodialysis, good pedal artery type before EVT, and low small artery disease score showed significant interaction effects on wound recurrence, favouring non-PAA over PAA. Subanalysis of changes in plantar arch artery morphology before EVT and during repeat angiography at the time of wound recurrence showed statistically significantly more frequent deterioration of plantar arch artery morphology in the PAA group than in the non-PAA group (p = .020). CONCLUSION:This study showed a significantly greater wound recurrence rate and more frequent deterioration of plantar arch artery morphology after PAA than after a non-PAA treatment in patients with CLTI.
BACKGROUND:The impact of cardiovascular surgery on balance function decline has not been well characterized. OBJECTIVES:This study investigated the frequency, associated factors, and prognostic significance of balance decline after cardiovascular surgery in older patients. METHODS:This observational study included patients aged 65 years or older who underwent elective cardiovascular surgery. Balance function was assessed using the Functional Reach Test before surgery and at discharge. Balance decline was defined as a reduction of at least 8 cm, based on previously reported minimal detectable change. Logistic regression identified factors associated with balance decline, and Cox regression assessed its prognostic impact. RESULTS:A total of 393 patients were analyzed (median age, 75 years). The prevalence of Functional Reach Test < 26.0 cm, indicating reduced mobility, increased significantly after surgery (preoperative 10.9% vs. postoperative 17.8%, p < 0.001). Balance decline occurred in 10.4% (n = 41). In multivariate analysis, higher N-terminal pro-brain natriuretic peptide, lower knee extensor strength, and longer operative time were significantly associated with balance decline (all p < 0.05). Patients with balance decline during hospitalization had a higher mortality rate than those without (p < 0.001). This association remained significant after adjusting for age, N-terminal pro-brain natriuretic peptide, and knee extensor strength at discharge (adjusted hazard ratio, 3.03; 95% confidence interval, 1.49-6.14; p = 0.002). CONCLUSION:Balance function decline after cardiovascular surgery was an independent predictor of poor prognosis in older patients. This decline was associated with preoperative cardiac dysfunction, reduced muscle strength, and longer operative time.
