J INVASIVE CARDIOL 2017;29(6):E72-E73.
Key words: peripheral vascular disease, aortic valve replacement
An 83-year-old woman presented with severe symptomatic aortic stenosis. Echocardiography revealed a heavily calcified and stenotic aortic valve, with an area of 0.56 cm2 and a mean gradient of 68 mm Hg. Given her preoperative Society of Thoracic Surgeons score of 13.6%, the heart team concurred that a transcatheter approach was most suitable. CT angiography revealed poor transfemoral access due to severe bilateral calcification with minimal luminal diameters of 2.7 mm and 3.4 mm of the right and left common iliacs, respectively. She was felt to be high risk for transthoracic access due to severe lung disease, baseline frailty, and poor rehabilitation potential. Due to baseline renal insufficiency and the extent of iliofemoral disease, we deferred a peripheral intervention and opted to proceed with percutaneous transaxillary transcatheter aortic valve replacement (TAVR).
Percutaneous transaxillary TAVR was performed utilizing our previously described technique for large-bore access and dry closure.1 A 6 Fr 3DR catheter was utilized to selectively engage the left subclavian artery. Angiograms of the subclavian and axillary arteries were performed to confirm sufficient luminal diameter. A 0.018˝ High-Torque Steelcore guidewire (Abbot Vascular) was advanced into the brachial artery through the 6 Fr 3DR catheter and road map angiography was performed. The second portion of the left axillary artery was then cannulated under direct fluoroscopic visualization using a micropuncture needle. A 4 Fr sheath was then placed and access-site angiography was performed. A 75 cm Amplatz Super Stiff guidewire (Boston Scientific) was advanced into the ascending aorta. The axillary artery was pre-closed using two Perclose ProGlide devices (Abbott Vascular) in standard fashion.
An 8 Fr sheath was then inserted and a Confida guidewire (Medtronic) was placed into the ascending aorta. A 16 Fr transfemoral Edwards eSheath (Edwards Lifesciences) was advanced under fluoroscopy into the proximal left subclavian artery. A 20 mm Sapien-3 transcatheter heart valve (Edwards Lifesciences) was then routinely delivered through the Commander delivery system (Edwards Lifesciences), positioned, and successfully deployed.
After echocardiographic assessment, the delivery system was removed and a 0.035˝ wire was inserted through the eSheath, which was then slowly withdrawn into the distal subclavian artery. Next, an 8 x 40 mm Mustang balloon (Boston Scientific) was advanced over the Steelcore guidewire and inflated to 4 atm proximal to the axillary arteriotomy site, to perform “dry closure” and avoid blood extravasation. The sheath was then removed and suture-mediated closure was completed. The balloon was deflated and axillary artery angiogram was performed through the balloon. No access-related vascular or neurological complications occurred.
Peripheral vascular disease is a common problem in TAVR candidates, with one-third suffering from severe peripheral artery disease.2,3 In this population, femoral approach remains difficult despite dramatic reduction in sheath sizes and improvements in delivery systems. The axillary artery is an alternative, large-caliber vessel that can be utilized in the presence of hostile aortoiliac segments. It can accommodate sheaths with an outer diameter up to 18 Fr and is less frequently affected by atherosclerosis than the femoral arteries.1,4
Percutaneous transaxillary TAVR is an option in patients with severe peripheral vascular disease who are at higher risk for transthoracic approach, which can be performed with procedural time, contrast, and equipment similar to standard transfemoral TAVR.
1. Tayal R, Barvalia M, Rana Z, et al. Totally percutaneous insertion and removal of Impella device using axillary artery in the setting of advanced peripheral artery disease. J Invasive Cardiol. 2016;28:374.
2. Petronio AS, De Carlo M, Bedogni F, et al. 2-year results of CoreValve implantation through the subclavian access: a propensity-matched comparison with the femoral access. J Am Coll Cardiol. 2012;60:502-507.
3. Modine T , Obadia JF, Choukroun E, et al. Transcutaneous aortic valve implantation using the axillary/subclavian access: feasibility and early clinical outcomes. J Thorac Cardiovasc Surg. 2011;141:487-491.
4. Tayal R, Iftikhar H, LeSar B, et al. CT angiography analysis of axillary artery diameter versus common femoral artery diameter: implications for axillary approach for transcatheter aortic valve replacement in patients with hostile aortoiliac segment and advanced lung disease. Int J Vasc Med. 2016;2016:3610705. Epub 2016 Mar 27.
From the Department of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Tayal and Dr Russo report speaker’s bureau fees from Edwards Lifesciences. The remaining authors report no conflicts of interest regarding the content herein.
Manuscript accepted April 11, 2017.
Address for correspondence: Rajiv Tayal MD, MPH, Department of Cardiology, Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112. Email: Rajtayalmd@gmail.com