The Role of the Axillary Artery as a Second Access Choice in TAVI Procedures

Abstract

With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVIeligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.

Left Axillary Access for Transcatheter Aortic Valve Implantation in a Patient With Two Dependent Internal Mammary Artery Grafts and a Permanent Left-Sided Implanted Pacemaker

“…Transaxillary access is considered widely as the second vascular approach option for TAVI after the transfemoral route [2][3][4]. Data derived from large randomized controlled TAVI trials and national registries have confirmed its non-inferiority to the transfemoral access with regards to procedural success, life-threatening bleedings, major vascular complications and comparable end points in terms of cardiovascular death and survival at 2 years [5][6][7][8].…”

“…Transaxillary approach accounts to approximately 5-10% of patients eligible for transcatheter aortic valve implantation (TAVI) [ 1 , 2 ]. Patients with severe aorto-iliofemoral artery disease are considered suitable candidates; however, technical considerations arise in cases with previous surgical interventions in the thorax potentially compromising the outcome of a subsequent intervention [ 2 , 3 ].…”

The Transaxillary Approach via Prosthetic Conduit for Transcatheter Aortic Valve Replacement With the New-Generation Balloon-Expandable Valves in Patients With Severe Peripheral Artery Disease

“…The use of TAx TAVR is well-known for years and was described in 2008 for the first time ( 15 ). Since then, several technical improvements and increased operator familiarity with the method contributed to making this approach the second choice in many TAVR centers ( 24 ). Most subclavian registries, describing the subclavian approach, were technically TAx given the infraclavicular approach.…”

“…Some studies are promoting the completely percutaneous use of the TAx-TAVR technique. However, implantation rates of covered stents due to vascular complications or insufficient closure with vascular closure devices are observed in up to 50% of the patients, promoting further stent-related complications and driving interventional costs (24,(26)(27)(28).…”