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Frail older adults undergoing transcatheter aortic valve replacement (TAVR) may not tolerate non-femoral access as well as do other peers, according to a post hoc analysis of the FRAILTY-AVR study.

These patients were more likely to die shortly after a more invasive non-femoral TAVR at both 30 days (9% versus 4% with femoral access, adjusted OR 3.91, 95% CI 1.48-10.31) and 1 year (24% versus 17%, adjusted OR 1.98, 95% CI 1.00-3.93).

In contrast, survival among non-frail patients was similar with femoral and non-femoral access for the procedure, reported Jonathan Afilalo, MD, MSc, of Jewish General Hospital in Montreal, and colleagues in their study published online in .

"This study builds on the existing literature that has shown non-femoral access to be consistently associated with less favorable post-procedural outcomes," the authors noted.

The FRAILTY-AVR analysis included 723 older adults getting TAVR at 14 participating centers in the U.S., Canada, and France out of the larger group of transcatheter and surgical valve patients ages 70 to 99 in the original analysis. Mean age was 84 years, and 55% of the group were men.

Procedures were performed in 2012 through 2017, with operators opting for femoral access in 77% of cases. Non-femoral alternatives were apical, direct aortic, axillary/subclavian, and carotid access.

The researchers acknowledged that they didn't know the reasoning behind access site decisions.

Frailty was assessed using the Essential Frailty Toolset, which combines lower-extremity muscle weakness, cognitive impairment, anemia, and hypoalbuminemia into a scale on which scores of 3 or higher indicate frailty. Using this scale, 35% of the study population was deemed frail.

One reason why frailty and non-femoral access might work against each other could be that TAVR becomes more invasive when it's not done through the thigh, according to Afilalo's group. "Non-femoral TAVR procedures necessitate larger incisions and general anesthesia, resulting in longer hospitalizations and slower resumption of physical activities, hence predisposing to deconditioning."

The second reason may be related to the finding that non-femoral TAVR patients more often had peripheral artery disease (PAD), which "represents a state of systemic vascular inflammation associated with an elevated risk of cardiovascular events and mortality," the investigators suggested.

"Taken together, pre-operative frailty, operative stress, and PAD may synergistically contribute to the inflammatory milieu that promotes sarcopenia, deconditioning, and adverse outcomes," they wrote.

However, they maintained, frailty "should not be equated with non-operability, but rather integrated alongside clinical and anatomical factors to tailor the procedural approach and peri-procedural care of these vulnerable patients."

In an accompanying editorial, David Holmes, Jr., MD, of the Mayo Clinic in Rochester, Minnesota, said he agreed with that approach. "Frailty is an important multidimensional syndrome. It rarely travels alone -- instead it may be observed traveling together with other company in several scenarios in which there may or may not be a causal relationship or just an association."

"Patients in whom transfemoral procedures cannot be performed usually have more extensive vascular disease with advanced peripheral arterial disease or small vessels documented during preprocedural imaging and they typically have more associated co-morbidities," the editorialist wrote, noting that these conditions are usually not modifiable (although smaller catheters and sheath sizes may help).

"In all cases, particularly in frail patients, those factors responsible for frailty must be evaluated and if possible ameliorated before proceeding with TAVR," according to Holmes.