Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation

Abstract

Transcatheter aortic valve implantation (TAVI) has gained widespread acceptance as a treatment option for patients at high risk for conventional aortic valve replacement. The most commonly used access site for TAVI is the common femoral artery. Yet, in a significant number of patients the transfemoral access is not suitable due to peripheral vascular disease of the lower extremity. In these cases the transaxillary approach can serve as an alternative implantation route. By considering the anatomical requirements and providing an adequate endovascular "safety-net" during the procedure the transaxillary TAVI approach results in excellent procedural and clinical outcome. However, whether the transaxillary access for TAVI is superior to other non-transfemoral approaches (e.g., transapical or direct aortic) needs to be studied in the future in a prospective randomized trial.

Keywords: Aortic stenosis; axillary artery; transcatheter aortic valve implantation (TAVI).

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1

Anatomy of the axillary artery. The axillary artery (red) begins at the lateral border of the first rib, runs posterior to the pectoralis minor muscle (pm), anterior to the teres minor muscle (tm) and becomes the brachial artery at the inferior border of tm. It is divided in three segments. The first segment (A) is located between the lateral border of the first rib and the medial border of pm; the second segment (B) is behind pm; the third segment (C) lies between the lateral border of pm and the inferior border of tm. Ideal puncture site for transaxillary TAVI is the first vessel segment. TAVI, transcatheter aortic valve implantation.

Figure 2

Installation of a long safety-wire providing retro- and antegrade endovascular access in case of vascular complication. A long safety-wire (dashed line) is introduced into the brachial artery ipsilateral to the TAVI access site and externalized through the common femoral artery. It provides retro- and antegrade endovascular access to the puncture site in case urgent treatment of a vascular complications (e.g., leakage or dissection) becomes necessary. TAVI, transcatheter aortic valve implantation.

Figure 3

Fluoroscopy during percutanous transaxillary TAVI. An uninflated PTA-balloon (red arrow) is introduced over the long safety-wire into the descending aorta before placement of the large sheath for valve implantation and is left in place during the following TAVI procedure in case blockade of the access vessel is needed (A and B). TAVI, transcatheter aortic valve implantation.

Figure 4

Result after transaxillary TAVI. Only a small skin incision is apparent after successful, truly percutaneous transaxillary TAVI. TAVI, transcatheter aortic valve implantation.