Coronary Sinus Reducer Implantation Via Axillary Venous Access: When the Jugular Route Fails.

OBJECTIVE: We describe right axillary venous access as a bailout strategy for coronary sinus reducer (CSR) implantation after failure of the conventional right internal jugular approach. KEY STEPS: Right jugular access failed because of unfavorable catheter-coronary sinus (CS) ostium alignment. Right axillary access using a 35° caudal projection provided a favorable trajectory. A Josephson catheter facilitated CS engagement, followed by 9-F guiding-catheter advancement using a mother-and-child technique and successful CSR deployment. POTENTIAL PITFALLS: Axillary puncture should avoid the lung field, and inadvertent arterial access must be excluded before sheath insertion. During the mother-and-child technique, excessive forward pressure may cause CS injury or perforation. Forceful contrast injection through a wedged catheter and inadequate support during device deployment should be avoided. TAKE-HOME MESSAGE: Axillary access may provide an effective bailout strategy for CSR implantation when conventional jugular access fails.