Transaxillary Transcatheter Aortic Valve Replacement: A Technical Narrative.

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) valve delivery is usually achieved transfemorally. Unfavorable iliofemoral anatomy can preclude transfemoral valve delivery, and alternative arterial access should be considered. We describe our preferred technique in transaxillary TAVR. KEY STEPS: 1) Radial or femoral arterial access for pigtail catheter placement; 2) femoral venous access for temporary pacemaker placement; 3) axillary artery exposure, control, and access; 4) root aortography; 5) aortic valve crossing; 6) advancement of the valve delivery system; 7) valve deployment; and 8) removal of the valve delivery system, repair of the axillary arteriotomy, and wound closure. POTENTIAL PITFALLS: 1) Arterial access site bleeding or stenosis; 2) arterial thrombosis; 3) axillary artery dissection; and 4) significant atherosclerosis interfering with arteriotomy repair. TAKE-HOME MESSAGE: Transaxillary arterial access for TAVR is a safe alternative valve delivery route, should be considered the first alternate access choice, and provides an efficient, effective, and reproducible technique when transfemoral access is prohibitive.