Axillary TAVR under locoregional anesthesia in a patient with peripheral artery disease.

Transcatheter aortic valve replacement (TAVR) is now a relatively commonly performed procedure and the number of eligible patients is growing exponentially.  In candidates with peripheral arterial disease, the axillary artery approach is an option worth considering. Usually TAVR performed using this approach is done under general anesthesia with tracheal intubation. At our center, however, we have developed a surgical approach to TAVR using the axillary artery under locoregional anesthesia.  This video tutorial demonstrates the technical details of our strategy. Because this procedure is extrathoracic, spares cerebral vessels, and is done under locoregional anesthesia, it is particularly suitable for fragile patients. This combination of both axillary access and locoregional anesthesia has the potential to become a primary main alternative for non-femoral TAVR patients and we hope it will be adopted also by other centers.

Axillary Transcatheter Aortic Valve Replacement in Patients With Peripheral Vascular Disease.

The axillary artery seems an interesting alternative in nonfemoral transaortic valve replacement (TAVR) patients. This study describes our experience with this technique and its short-term follow-up results. This is a retrospective single center study. All axillary TAVR performed in our department between 2015 and 2017 were included in the study. Mean follow-up was 13.2 ± 9.5 months. All reporting was done according to the VARC-2 criteria. During the period covered, 43 patients had an axillary TAVR. Most patients were men (62.7%), had a mean age of 83.9 ± 5.3 years and presented with EuroSCORE I, II, and STS score of 27.9 ± 13.5%, 5.6 ± 4.9%, and 7.7 ± 4.05%, respectively. Vascular access was successful in all patients with a higher frequency of left approach (69.7%, n = 30). Both Medtronic CoreValve 37.2% (n = 16) and Edwards Sapien3 62.8% (n = 27) valves were used. An apical Certitude delivery system was preferentially used (24/27) in the latter group. There were no reported instances of valve migration or need for a second valve implantation. A single case (2.3%) of arterial vascular complication was reported. Central neurologic morbidity was 2.3%. No patient experienced brachial plexus injury. A pacemaker was implanted in 18.6% of cases (n = 8), with no significant difference between the 2 valves patient groups (S3 14.8% vs CV 25%, P 0.67). The 30-day mortality was 6.9% (n = 3) and 1-year survival was 86% [95% CI 72.6, 93.4]. Axillary TAVR is associated with acceptable morbidity, mortality, and leads to satisfactory short-term clinical outcomes. It has the potential to become the main alternative access route in nonfemoral TAVR patients.

Radial versus femoral access for coronary angiography and intervention is associated with lower patient radiation exposure in high-radial-volume centres: Insights from the RAY'ACT-1 study.

BACKGROUND: Literature suggests that radial access is associated with higher radiation doses than femoral access. AIMS: To compare patient radiation exposure during coronary angiography (CA) and percutaneous coronary intervention (PCI) with radial versus femoral access. METHODS: RAY'ACT is a nationwide, multicentre, French survey evaluating patient radiation in interventional cardiology. Variables of patient exposure from 21,675 CAs and 17,109 PCIs performed at 44 centres during 2010 were analysed retrospectively. RESULTS: Radial access was used in 71% of CAs and 69% of PCIs. Although median fluoroscopy times were longer for radial versus femoral access (CA, 3.8 vs 3.5minutes [P<0.001]; PCI, 10.4 vs 10.1minutes [P=0.001]), the Kerma-area product (KAP) was lower with radial access (CA, 26.8 vs 28.1Gy·cm2; PCI, 55.6 vs 59.4Gy·cm2; both P=0.001). Differences in KAP remained significant in the multivariable analysis (P<0.01), and in a propensity score-matched analysis (P=0.01). A significant interaction was found between KAP and the percentage of procedures with radial access by centre (P<0.001). KAP was higher by radial versus femoral access in low-radial-volume centres, and lower in high-radial-volume centres. Radiation protection techniques, such as the use of low frame rates (7.5 frame/s), were used more frequently in high-radial-volume radial centres. CONCLUSIONS: In this multicentre study, radial access was associated with lower radiation doses to patient than femoral access in high-radial-volume centres. Provided that radioprotection methods are implemented, radial access could be associated with lower patient radiation exposure.