The “Chimney approach” for transcatheter aortic valve implantation: A strategy for trans axillarian bareback approach in patients with no other access options

Abstract

In this initial experience, the axillarian bareback approach technique allowed a safe and successful TAVI implant in a subgroup of patients with a high risk of procedural complications due to the presence of a patent LIMA-LAD or vessels of small caliber. Considering the increasing number of patients referred for TAVI, in the next future the axillarian bareback approach could represent a safer alternative to direct cannulation in patients with severe aortic stenosis with no other access options.

Access Sites for TAVI: Patient Selection Criteria, Technical Aspects, and Outcomes

“…Once isolated, a single or double purse string suture is placed on the subclavian artery and access to lumen is achieved by means of a direct puncture. In selected cases, a 10–12 cm Dacron vascular graft can be anastomosed end-to-side to the subclavian artery with and a standard large femoral sheath (>18F), custom modified by cutting the distal portion in order to allow to accommodate the sheath inside the vascular graft without extending its distal edge into the subclavian artery ( 34 ) (Figures 5D,E ). This modified technique avoids extensive manipulation of the artery in case of borderline vascular diameter allowing a safe implantation even in patients with patent left internal mammary artery to the left anterior descending coronary artery.…”

Percutaneous axillary arteriotomy closure during transcatheter aortic valve replacement using the MANTA device

“…Axillary TAVR access can be performed under open direct vision using surgical skills and a purse‐string suture of the arteriotomy or more a complex technique involving externalised Dacron® graft . The percutaneous approach has been described using a guidewire (for both “safety,” to allow balloon tamponade/covered stenting, and to help guide puncture) from the ipsilateral brachial artery.…”

Severely regurgitant left ventricle to ascending aorta conduit in a failing fontan patient treated with a vascular endograft and melody transcatheter pulmonary valve via hybrid approach

“…Given the patient's unique anatomy, hybrid surgical access via a vascular graft provided an ideal approach for intervention in our patient. This approach has been utilized in adult patients to facilitate the implantation of transcatheter aortic valves and catheter‐based Impella ® left ventricular assist devices (ABIOMED, Inc. Danvers, MA) . In addition to limiting the injury of the axillary artery, the tube graft provided additional vascular length for manipulation of the 100 cm long delivery system.…”