Age-Related Excessive Tortuosity of the Right Brachiocephalic Artery in Patients Being Evaluated for Transcatheter Aortic Valve Replacement (TAVR): Potential to Affect Alternate Access.

Background We hypothesized age-related excessive tortuosity of the right brachiocephalic artery (RBCA) in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. Methods This single-center, retrospective, cross-sectional study evaluated 100 consecutive patients aged ≥70 undergoing TAVR workup. Contrast-enhanced computed tomography (CT) angiography of the chest, abdomen, and pelvis was performed, and three-dimensional volume-rendered reconstructions were generated. Tortuosity of the RBCA was quantified based on the number and degree of angulations (≥45° or ≥90°). Results Of the 100 patients, the mean age was 80.6 years, there were 53 females, 37 diabetics, and 99 hypertensives, the mean low-density lipoprotein (LDL) was 81.8 mg/dL, the mean ejection fraction was 57.1%, and the mean of the mean aortic valve gradients was 33.6 mmHg. About 88% of the patients had a varying combination of at least up to two angulations ≥45° and/or ≥90°, while 47% had at least two angulations ≥90°. Conclusions Incidence of excessive tortuosity of the RBCA in the elderly being evaluated for TAVR is indeed very high; 88% of the patients had a varying combination of at least up to two angulations ≥45° and/or ≥90°, while 47% had at least two angulations ≥90° (normal in young healthy subjects being no angulations at all ≥45° and/or ≥90°). This excessive RBCA tortuosity may affect the ease and success of procedures performed using the right axillary approach, particularly for TAVR alternate access (percutaneous axillary (PercAx)). Larger studies are needed to corroborate our findings not only in patients with aortic stenosis being evaluated for TAVR but also in this age group in general, since such excessive RBCA tortuosity may, to some degree, explain the increased incidence of radial-to-femoral conversion with advancing age.