Author + information
- Nilesh J. Goswami, MD∗ ( and )
- Greg Mishkel, MD, MBA
- ↵∗Prairie Heart Institute, 619 East Mason Street, Springfield, Illinois 62794
Given Dr. King's history of accomplishments in the development of interventional cardiology as a specialty, it is of interest to reflect back on the early results of balloon angioplasty, where the early success rates were only 64% (32 of 50 patients) (3). Through Dr. Gruntzig’s and Dr. King’s experience and efforts, percutaneous coronary interventions have now become a standard procedure across the world despite its initial suboptimal results.
In comparison, the Greenbaum et al. (4) series of the first 100 transcaval cases yielded a success rate of 99%, and has been performed on at least 230 patients worldwide. Despite this impressive success rate, Dr. King advised caution with adoption of this technique and advised “don’t try this at home,” suggesting that this technique be reserved for high-volume centers instead of being used by all operators. This of course begs the question: What is a high-volume center? There are an estimated 450 transcatheter aortic valve replacement centers in the United States. The volumes at these sites range widely from 2 cases per month up to over 500 cases per year. Specific to transcaval access, what number of procedures using this technique denotes a “high-volume center”?
Surely, we should be more concerned about high quality rather than high volume. Rather than the allusion to the television show, “Don't try this is at home”; we would suggest an alternative television show, hosted by John Quiñones on ABC and titled “What Would You Do? This was indeed the question that our site needed to answer in 2016, as we considered adding transcaval access to our percutaneous transfemoral, surgical transaortic, transapical, trans-subclavian procedures with a volume 160 transcatheter aortic valve replacement cases that year.
Our own thoughts, given our laboratory's experience with relatively standard interventional or endovascular techniques, were that the requirements for transcaval were not that dissimilar. We undertook to implement this technique in an organized and structured fashion as follows:
1. We initiated a conversation with an experienced operator (Dr. Greenbaum);
2. We observed the procedure, as presented at many interventional conferences. Anecdotally, a European site in Copenhagen has completed 5 cases after watching a single YouTube video;
3. We examined the literature and learned from other's mistakes;
4. With this knowledge in hand, we developed our inventory and procedural algorithm, as well as ensuring we had what was needed to handle any possible complications;
5. We had a proctor for the initial cases;
6. We critically examined the results, successes and otherwise, after each case. We were prepared to abandon the practice if results were unacceptable.
What was the outcome? Our site felt comfortable after two proctored cases, and to date now have performed 8 transcaval procedures over the past 10 months (7 transcatheter aortic valve replacements, 1 thoracic endovascular aortic repair). Fortunately, we have not had any complications related to this access. In 6 of 8 cases (75%), the aortocaval fistula was closed completely at the end of the procedure. This is in contrast to the 36% immediate closure rate seen in the first 100 patients reported, demonstrating how operators can learn from other's experience.
The moral of this battle of the television shows is that this technique can be applied successfully by interventional cardiologists with relatively standard interventional and endovascular training, and they can develop and institute such a technique independent of their volume, though dependent on using a quality-based approach. Based on our experience, it appears that even after a few proctored cases, the procedure can be done successfully and safely.
Dr. King, along with the early pioneers of interventional cardiology, displayed courage and conviction in developing the techniques of percutaneous coronary intervention even despite mediocre initial results. Today's generation of interventionalists should adopt a similar mindset to develop their skills with all new techniques. Based on our experience, we would argue that transcaval access is not a “disruptive technology” that “should not be tried at home.” It is a potentially valuable skill that can allow for safe, alternative access for those patients with severe aortic stenosis and iliofemoral arterial occlusive disease.
What will you do?
Please note: Dr. Goswami has reported that he has no relationships relevant to the contents of this paper to disclose. Dr. Mishkel has received speaker honoraria from Edwards Lifesciences and has served as a proctor for Boston Scientific.
- 2017 American College of Cardiology Foundation
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