Percutaneous trans-axilla transcatheter aortic valve replacement

Figures

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  Fig. 1. Angiography, schematic illustration, and access site of trans-axilla TAVR A The axillary artery begins at the lateral border of the first rib, as a continuation of the subclavian artery. The axillary artery is divided into three segments based on its relation to the pectoralis minor muscle. The first, second, and third segments (i.e., proximal, middle, and distal segments) are medial, posterior, and lateral of the pectoralis minor muscle. The puncture site should be within the third segment of the axillary artery, considering the anatomical relationship to the humeral head. The access point at the third segment of the axillary artery can be compressed against the neighboring osseous structures to control bleeding during sheath removal; B angiography of the subclavian and axillary arteries, showing a puncture needle (triangle arrowheads) pointing at the third segment of the axillary artery, which is normally proximal of the take-off of the anterior humeral circumflex artery asterisk and subscapular artery double asterisk; C a long J-tip wire is advanced into the axillary artery as a landmark for the puncture and kept in place as a safety measure in case of bleeding complications.…

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  Fig. 2. Schematic illustration of trans-axilla TAVR set-up shown is the set-up for a trans-axilla TAVR. A pig-tail catheter is placed through an 8F long sheath via the femoral artery for the injection of dye. Also, a safety wire is placed in the axillary artery through the femoral sheath.

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  Fig. 3. Retrieving the THV sheath and vascular management. A An angioplasty balloon double asterisk and the 8F long sheath are advanced into the subclavian artery. A balloon blockade is performed during retrieval of the THV sheath, in order to minimize the bleeding from the puncture site. A J-tip wire via the femoral artery remained in the axillary artery to secure an access route for stent implantation, in case of significant bleeding, perforation, or flow-limiting dissection; B after the two sutures of the ProGlide® system are tied down, control angiography is performed using the 8F-80 cm sheath via the femoral artery. The access point at the third segment of the axillary artery can be compressed against the neighboring osseous structures to control bleeding during sheath removal