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J Thorac Cardiovasc Surg 2009;137:773-775
© 2009 The American Association for Thoracic Surgery

Brief Communication

Transcatheter aortic valve intervention through the axillary artery for the treatment of severe aortic stenosis

^a Department of Cardiac Surgery, Royal Brompton Hospital, and NHLI at Imperial College, London, UK
^b Department of Cardiology, Royal Brompton Hospital, and NHLI at Imperial College, London, UK
^c Department of Anesthesia, Royal Brompton Hospital, and NHLI at Imperial College, London, UK

Received for publication December 17, 2007; revisions received December 17, 2007; accepted for publication December 19, 2007.

^_* Address for reprints: Neil Moat, MS, Department of Cardiac Surgery, Royal Brompton Hospital, and NHLI at Imperial College, London SW3 6NP, UK. (Email: N.Moat{at}rbht.nhs.uk).

Transcatheter aortic valve implantation (TAVI) has been proposed as an alternative to conventional surgery for high-risk patients and has been successfully effected through both the transfemoral¹ and transapical² approaches. The femoral route can be difficult in patients with small or diseased iliofemoral arterial systems that either prevent access, result in procedural failure, or cause major vascular injury. The transapical approach avoids these problems; however, the apex of the left ventricle can be a friable and unforgiving structure in the older patient. In addition, a small anterolateral thoracotomy is required for the transapical approach, and this can be a problem in cases of severe respiratory dysfunction. We describe a trans–axillary artery technique for TAVI in a patient with severe lung disease and peripheral vascular disease to illustrate this approach, along with its potential advantages and limitations.

Clinical Summary

The patient was a 71-year-old woman with a long history of bronchiectasis and Pseudomonas colonization. She was seen for increasing breathlessness during the previous 9 months resulting in numerous hospitalizations. She was found to have no significant deterioration in her preexisting respiratory function. Cardiac investigations determined the presence of severe aortic stenosis, with a peak transvalvular gradient of 97 mm Hg and a valve area of 0.63 cm². Angiography revealed nonsignificant coronary artery disease but bilateral small and diffusely diseased femoral arteries.

The patient was subsequently discussed at our Structural Heart Multi-Disciplinary Meeting and was considered to face a prohibitively high risk with conventional aortic valve replacement. She was referred to our TAVI program, and protocol-driven transthoracic echocardiography and aortography confirmed adequate anatomic parameters for transcatheter valve replacement. The small diseased femoral arteries made the transfemoral approach unsuitable. In light of her significant respiratory dysfunction, we believed that a small thoracotomy would also pose a significant risk. Angiography demonstrated a healthy aortic arch with nondiseased and good-sized left subclavian and axillary arteries, and the decision was made to proceed through the axillary approach.

The proximal axillary artery was exposed through a small infraclavicular incision, and the 18F sheath was inserted through a transverse arteriotomy. The tip of the sheath was advanced into the mid ascending aorta (Figure 1 ), and the CoreValve self-expanding nitinol prosthesis (CoreValve Inc, Irvine, Calif) was implanted in the standard manner (Figure 2 ). The prosthesis was well positioned, with no significant residual transvalvular gradient and only trivial aortic regurgitation. The patient made an uneventful recovery, apart from high-grade atrioventricular block necessitating a permanent pacemaker. At 5 months after the procedure, she was doing well, her symptomatic status has improved markedly, and she was delighted with the outcome.

View larger version (186K): [in this window] [in a new window]   Figure 1. Positioning of delivery sheath into aorta through axillary artery.

View larger version (201K): [in this window] [in a new window]   Figure 2. Deployment of CoreValve prosthesis (CoreValve Inc, Irvine, Calif) into aortic position.

TAVI is an emerging field with the potential to provide relief of aortic stenosis for a high-risk patient population.^3,4 There still are many as yet unresolved difficulties with these technologies. Two of the major concerns are the access route to the diseased valve and the ability to accurately position the prosthesis.⁵ Although smaller sheathes and other improvements in technology will facilitate a transfemoral approach, this access route will still be challenging in a significant proportion of cases for the foreseeable future. The transapical route is an option for these patients and may have some advantages with respect to ease of device positioning and implantation. It may not, however, be suitable for patients with severe respiratory dysfunction.

The axillary approach is simple and familiar to cardiac surgeons. The subclavian and proximal axillary arteries are usually good-sized vessels and are often free of atherosclerotic disease. We have used this approach successfully for 2 additional patients; in all 3 cases, exposure of the vessel, insertion and removal of the 18F sheath, and vessel repair were easy and uncomplicated. This approach provided good stability of the sheath and valve delivery system, with what appeared to be simpler device positioning and implantation relative to the transfemoral approach. A patent left internal thoracic artery graft is probably a contraindication to a left axillary approach. The potential to compromise innominate artery flow is a relative contraindication to the right axillary approach.

The trans–axillary artery approach offers an additional tool in the new armamentarium for the treatment of aortic stenosis in patients who are candidates for TAVI but who have significant respiratory dysfunction and problematic iliofemoral access precluding the other available techniques. We also believe that it offers some advantages relative to the transfemoral and transapical approaches and is worthy of evaluation in a broader patient population as an alternative access route.

References

1. Webb JG, Chandavimol M, Thompson C, Ricci DR, Carere R, Munt B, et al. Percutaneous aortic valve implantation retrograde from the femoral artery. Circulation 2006;113:842-850.[Abstract/Free Full Text]
   
2. Ye J, Cheung A, Lichtenstein SV, Pasupati S, Carere RG, Thompson CR, et al. Six-month outcome of transapical transcatheter aortic valve implantation in the initial seven patients. Eur J Cardiothorac Surg 2007;31:16-21.[Abstract/Free Full Text]
   
3. Grube E, Schuler G, Buellesfeld L, Gerckens U, Linke A, Wenaweser P, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome. J Am Coll Cardiol 2007;50:69-76.[Medline]
   
4. Cribier A, Eltchaninoff H, Tron C, Bauer F, Agatiello C, Sebagh L, et al. Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis. J Am Coll Cardiol 2004;43:698-703.[Medline]
   
5. Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, et al. Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis. Circulation 2007;116:755-763.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mario Petrou Neil Moat Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Asgar, A. W. Articles by Moat, N. Search for Related Content PubMed PubMed Citation Articles by Asgar, A. W. Articles by Moat, N.