Transaxillary Transcatheter Aortic Valve Implantation as First-Line Alternative to Transfemoral Access: A Single-Center Experience

Objectives: Since introduction of second- and third-generation transcatheter aortic valve implantation (TAVI) systems with smaller introduction sheathes use of alternative access routes to the transfemoral (TF) approach have decreased. Transaxillary (TAx) access preserves the option of a complete percutaneous, retrograde procedure, omitting myocardial injury and need for general anesthesia, and enables implantation of all established TAVI devices. We herein report our experience with this alternative approach.

Methods: Between 01/2014 and 02/2020, a total of 69 patients (78.2 ± 7.7 years, 60.2% male, logEuroSCORE I 24.1 ± 15.2%) received TAx-TAVI at our institution. Procedural setup comprised of a complete percutaneous access using the ProGlide (84.1%; 58/69) or Manta (15.9%; 11/69) systems and a safety net for the punctured vessel by externalizing a long wire via the ipsilateral brachial artery to the femoral artery. Implanted THV were: Medtronic CoreValve (27/69; 39.1%), Boston Scientific ACURATE neo (14/69; 20.3%), Edwards Sapien 3 (16/69; 23.2%), NVT Allegra (6/69; 8.7%), St. Jude Medical Portico (5/69; 7.2%), and one Edwards Centera (1.4%). Data were retrospectively analyzed according to updated Valve Academic Research Consortium (VARC-2) definitions.

Result: Procedure time, fluoroscopy time and contrast agent used were 135.2 ± 75.2 minutes, 43.5 ± 21.2 minutes, and 263.7 ± 108.1 mL, respectively. Device success and early safety were 95.6 and 85.5% with an all-cause 30-day mortality of 5.8% (4/69). Stroke, acute kidney injury, and access site complications occurred in 8.7% (6/69), 10.1% (7/69), and 10.1% (7/69), respectively. Postprocedural permanent pacemaker implantation was performed in 10.1% (7/69) of patients. Resultant transvalvular peak/mean gradients were 15.3 ± 7.4/ 7.5 ± 3.9 mm Hg. PVL ≥ moderate was observed in 4.3% (3/69) of cases. ICU and hospital stay time were 4.4 ± 6.6 and 13.5 ± 7.6 days.

Conclusion: TAx-TAVI is an adequate option in patients not eligible for TF access. Data suggest that this procedure offers a reasonable safety profile for a patient population at particular high risk. Therefore, TAx-TAVI has become first line alternative approach to TF access at our center and is performed as primary operator by both cardiac surgeons and cardiologists in the context of a dedicated heart team.

Publication History

Article published online:
19 February 2021