The Alternative Transaxillary Access for Transcatheter Aortic Valve Implantation

Background: Transcatheter aortic valve implantation (TAVI) is a well-established treatment option for patients at high risk for conventional aortic valve replacement. Nowadays, the transfemoral approach is approved as the first-choice access for TAVI. Nevertheless, in many cases, alternative approaches are necessary when the TF access is unsuitable. Transaxillary TAVI has been proven to be a safe and efficient alternative. We hypothesized that modified transaxillary access via the left brachial artery is feasible and safe to perform the TAVI and may be beneficial for patients.

Methods: Between December 2018 and February 2024, 24 patients (7 women, 77.9 ± 8 years) underwent transcatheter aortic valve implantation in transaxillary access via the left brachial artery in our clinic. Patients with symptomatic severe aortic stenosis (Pmean 43.8 ± 10.5 mm Hg; EOA 0.7 ± 0.2 cm²), qualified for TAVI with iliofemoral anatomy unsuitable for transfemoral approach, were included. The patient cohort showed high perioperative risk with log EuroScore 10.9 ± 10.6%, with severe peripheral artery disease (n = 16, 66.7% of cases) or severe occluding infrarenal aortic disease in remaining cases. The implantation of the aortic prosthesis was performed through the left brachial artery. The diameter of the artery was determined before intervention. After an incision in the medial bicipital groove, the brachial artery was exposed, and the purse-string suture was prepared for the implantation device. The procedure was executed in a standard manner with an unchanged TAVI setting.

Results: The balloon-expandable valve of 25.6 ± 2.4 mm diameter was implanted in all cases. The average intervention time was 102.6 ± 46 minutes, with an average fluoroscopy time of 20.8 ± 14.7 minutes. In the analyzed group, 30-day mortality was 4.2%, with one lethal complication due to aspiration and consecutive hypoxia. A new pacemaker had to be implanted in 4 patients (16.7%). In 2 cases, new moderate neurological dysfunctions were observed. One case of myocardial infarction due to coronary occlusion with consecutive stenting was noted. Only one patient required secondary surgical revision in the access site due to ischemia.

Conclusion: Our experience shows that transaxillary TAVI via the left brachial artery has shown promising results. This access is feasible and safe, does not prolong the intervention time, minimizes surgical trauma, provides excellent exposure independent of the chest anatomy, and spares the brachial plexus. Further comparative studies are required to evaluate this technique and to encourage the community for its broader application.

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Artikel online veröffentlicht:
11. Februar 2025