Transaxillary Transcatheter Aortic Valve Implantation (TRAX-TAVI) with Balloon Expandable Valve

This video demonstrates a step-by-step method for transaxillary transcatheter aortic valve implantation. The procedure utilizes the axillary artery, which lies beneath the clavipectoral fascia, medial, below, and lateral to the pectoralis minor muscle.

To begin the procedure, a small horizontal infraclavicular incision was made at the junction of middle and outer third of the clavicle, overlaying the deltopectoral groove. The pectoralis major was then dissected along its fibers. The clavipectoral fascia was incised, exposing the pectorals minor muscle. The axillary artery can be identified by palpation medial to the muscle and then exposed using sharp dissection. The artery was gently mobilized for 2 cm and looped with a vessel loop proximally and distally. The first branch of the superior thoracic artery was looped as well to have full control on the vessel.

Next, the vessel was punctured, and the guide wire was inserted. A 6 Fr. sheath was inserted using the Seldinger technique and crossed the aortic valve using soft Terumo wire and AL1 angiographic catheter. The soft Terumo wire was then replaced with stiff Safari wire. The team then completed a controlled transverse incision of the artery.

Next, a large, 18 Fr. bore sheath was guided using to avoid any damage to the artery. A balloon valvuloplasty and rapid ventricular pacing (RVP) were performed and valve insertion was performed using a transapical device. The valve was then deployed under RVP and final angiographic control of the valve position was performed. The sheath was then removed with simultaneous pulling on the vessel loops to control the bleeding. The arteriotomy was closed in an end-to-end fashion with 5.0 Prolene, and the wound was closed in layers.

References

1. Schofer N, Deuschl F, Conradi L, Lubos E, Schirmer J, Reichenspurner H, Blankenberg S, Treede H, Schäfer U. Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation. J Thorac Dis. 2015 Sep;7(9):1543-7. doi: 10.3978/j.issn.2072-1439.2015.07.27. PMID: 26543600; PMCID: PMC4598529.
2. Zhan, Y., Toomey, N., Ortoleva, J. et al. Safety and efficacy of transaxillary transcatheter aortic valve replacement using a current-generation balloon-expandable valve. J Cardiothorac Surg 15, 244 (2020). https://doi.org/10.1186/s13019-020-01291-z.
3. Schäfer U, Deuschl F, Schofer N, Frerker C, Schmidt T, Kuck KH, Kreidel F, Schirmer J, Mizote I, Reichenspurner H, Blankenberg S, Treede H, Conradi L. Safety and efficacy of the percutaneous transaxillary access for transcatheter aortic valve implantation using various transcatheter heart valves in 100 consecutive patients. Int J Cardiol. 2017 Apr 1;232:247-254. doi: 10.1016/j.ijcard.2017.01.010. Epub 2017 Jan 7. PMID: 28118931.

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