Transcatheter aortic valve implantation through distal axillary artery: novel option for vascular access

AIMS:We describe an alternative access approach for patients undergoing transcatheter aortic valve implantation (TAVI) using surgical cut down of the distal axillary artery, in cases wherein transfemoral access is not feasible.METHODS:From January 2012 to July 2013, 61 patients (59% men; mean age 81 ± 8 years) underwent TAVI at our institution. The mean logistic EuroSCORE and EuroSCORE II were 36 ± 24 and 14 ± 10, respectively. We assessed device success, 30-day safety and clinical efficacy using VARC II criteria.RESULTS:TAVI was performed with the CoreValve Revalving System (CRS) (Medtronic Inc., Minneapolis, Minnesota, USA) in all cases, using transfemoral approach in 57 patients and distal trans-axillary route in four patients. A device was successfully implanted in 94%, without any major intraprocedural complications. One case of acute kidney disease, four cases of minor vascular complication and two cases of life-threatening bleeding occurred after the procedure for pericardial bleeding requiring pericardiocentesis. Permanent pacemaker was implanted in 26% of patients. There was no instance of in-hospital mortality, while two deaths (3%) occurred in the first 30 days. The total procedure time (skin-to-skin) was longer in the trans-axillary group secondary to surgical management of access site (P = 0.027), whereas revalving and fluoroscopy time were similar (P = 0.95 and P = 0.83, respectively).CONCLUSION:The location and anatomical relations of the distal axillary artery make it a safer, reproducible and operator friendly access option for TAVI.