BACKGROUND
Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for severe aortic stenosis. Despite major advances, TAVR is still associated with several procedure-specific complications, such as vascular and bleeding events, that have a significant impact on mortality. In patients undergoing percutaneous coronary intervention, the transradial artery approach (TRA) has been shown to be superior to the transfemoral artery approach (TFA), resulting in lower rates of vascular complications. However, the impact of the different approaches for coronary angiography on outcomes in patients undergoing subsequent TAVR is not known.

OBJECTIVES
The aim of this observational study was to evaluate the impact of the TRA versus TFA for pre-procedural coronary angiography on outcomes in patients undergoing subsequent TAVR.

METHODS
Our study cohort included 1005 consecutive patients undergoing TAVR, of whom 397 (39,5%) had a prior coronary angiography with a TRA and 608 (60.5%) with a TFA. The selection of the appropriate approach was left to the discretion of the operator, who made the decision taking into account the safety and feasibility of the procedure. The primary endpoint of the study was a composite of 30-day all-cause mortality and major vascular complication. Key secondary end points included VARC-2 defined complications as well as bailout unplanned surgical and endovascular interventions.

RESULTS
The mean age of our study population was 81.0±6.5 years, 46% were of female gender. Regarding baseline characteristics, no relevant differences were detectable between the TRA and the TFA groups with comparable rates of peripheral artery disease (42.4% vs 40.7%, p=0.60) and coronary artery disease (60.9% vs 65.6, p=0.46). The primary endpoint occurred less frequently in patients with prior TRA as compared to patients with prior TFA, but just barely missed the significance (3.0% vs 5.4%, p=0.08). This was mainly driven by significantly lower rates of major vascular complications in the TRA group (0.8% vs 3.5%, p=0.05), as presented in Figure 1. Moreover, the TRA was associated with lower rates of major bleeding events (1.5% vs 3.5%, p=0.05), while no difference was detectable in the rates of life-threatening bleedings between the TRA and TFA group (0.5% vs 0.8%, p=0.71). Furthermore, the use of unplanned surgical or endovascular interventions was lower in patients with prior TRA (1.0% vs 3.0%, p=0.04).

CONCLUSION
The choice of the TRA for pre-procedural coronary angiography resulted in significantly lower rates of TAVR-related major vascular and major bleeding complications in patients undergoing subsequent TAVR as compared to patients with a TFA. Moreover, the need for unplanned surgical or endovascular interventions was significantly lower in patients with prior TRA.