Editorial Comment

The Roads Less Traveled

Larry Latson, MD, FSCAI

Cleveland ClinicCenter for Pediatric and Congenital Heart DiseasesCleveland, Ohio

In this issue of Catheterization and CardiovascularInterventions, Davenport et al. review their experiencewith the use of ‘‘nontraditional’’ routes of vascular accessto perform interventional catheterization procedures forstructural/congenital cardiovascular abnormalities [1].The alternative routes of vascular access they report uponare limited to the carotid, brachial, axillary, and radialarteries, the hepatic and brachial veins, and cannulationthrough an open chest. The authors used these alternativeroutes because the more conventional vessels for accesswere either unavailable or, in their opinion, were poten-tially too small or resulted in a less desirable angle orroute of approach. All target lesions were successfullyaccessed, and interventions were performed when thesealternate routes of access were utilized.

All of the routes of vascular access utilized in thisarticle have been previously described individually.This report nicely details the combined experienceusing alternate routes of vascular access in 54 casesover �9½ years in a busy congenital cardiovascularpractice. At least 38 of the 54 alternative routes wereaccessed with the assistance of a surgeon to place asheath under direct vision via a cut down or the openchest. There were only two relatively minor reportedcomplications related to the access route—a thrombusin a carotid artery that was successfully evacuated andthe need for a limited surgical cut down to remove aruptured balloon catheter from the transhepatic accesssite. At least some of the types of procedures reportedin this series (especially aortic balloon valvuloplasties)are completed quite successfully in many centersthrough traditional routes of vascular access. Theauthors have not conclusively shown that alternativeroutes of access in many of their cases are superior totraditional approaches, but they have shown that alter-native routes can be accessed with complication ratesthat are not clearly worse than traditional routes. Thisis valuable information, as performing a proceduremay well be technically easier and quicker from amore direct route. There are many ways to accomplishany procedure, and preferences may, quite reasonably,

relate to logistics and local experience if overall out-comes and complication rates are similar.It has become clear that catheter-based interventions

and devices have definite advantages over traditionalsurgical approaches for an ever expanding array of prob-lems. Getting specialized catheters and associated bal-loon and devices to critical areas safely, however, canbe difficult. By utilizing the skill sets of both the sur-geons and catheter interventionalists, a modern team canexpand the range of possible treatment options toinclude better routes of delivery of specialized catheterdevices. Every modern center specializing in treatmentof congenital/structural heart disease needs to have thecapabilities to access all of the alternate routes of accessenumerated by Davenport et al. [1]. Even more alterna-tive approaches to device placement, such as ventricularpuncture for placement of septal closure devices andcatheter-delivered valves, are being reported [2,3]. Whena catheter device is large or difficult to orient in an opti-mal direction or position, we should continue to keep anopen mind about alternate ways to deliver devices accu-rately in a beating heart. Every potentially optimal de-vice and approach should be considered by both the sur-geon and the interventionalists in our quest to providethe best and safest treatments for patients with cardio-vascular defects. In some cases, it may well be optimalfor the patient to use the nontraditional routes of accessor, to paraphrase the poet Robert Frost, to take the roadless traveled by, and this may make all the difference.

REFERENCES

1. Davenport JJ, Lam L, Whalen-Glass R, Nykanen DG, Burke RP,

Hannan R, Zahn EM. The successful use of alternative routes of

vascular access for performing pediatric interventional cardiac

catheterization. Catheter Cardiovasc Interv 2008;72:102–108.

2. Eltchaninoff H, Zajarias A, Tron C, Litzler PY, Baala B, Godin

M, Bessou JP, Cribier A. Transcatheter aortic valve implantation:

Technical aspects, results and indications. Arch Cardiovasc Dis

2008;101:126–132.

3. Lim DS, Ragosta M, Dent JM. Percutaneous transthoracic ven-

tricular puncture for diagnostic and interventional catheterization.

Catheter Cardiovasc Interv 2008;71:915–918.

Conflict of interest: Nothing to report.

*Correspondence to: Larry Latson, 9500 Euclid Ave., Dest M41,

Cleveland, OH 44195. E-mail: latsonl@ccf.org or ulbricc@ccf.org

Received 1 July 2008; Revision accepted 12 July 2008

DOI 10.1002/ccd.21735

Published online 25 August 2008 in Wiley InterScience (www.

interscience.wiley.com).

' 2008 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 72:399 (2008)