Axillary Cannulation for Large Bore Access Christian Shults

Axillary Cannulation for Large Bore Access Christian Shults, MD Assistant Professor, Georgetown University School of Medicine Co-Director, Aortic Surgery Director Surgical Ablation Medstar Heart and Vascular Institute

Christian Shults, MD I have no relevant financial relationships

Access Right Left CIA 4. 9 mm EIA 5. 1 mm 6. 3 mm CFA 3. 5 mm 4. 2 mm

Assessment • • • Centerline vessel diameter on CTA Tortuosity/kinking Patent mammary Approach to target landing zone Origin of innominate/LSCA for atherosclerosis/stenosis

Axillary Artery Considerations

Axillary Access ( 9/28/2016) Right Left P 8. 8 mm 5. 2 mm M 6. 9 mm 7. 4 mm D 6. 3 mm 6. 1 mm

Alternative Access Order of Preference (TAVR) 1. Trans-Caval 2. Trans-Axillary/Trans-Carotid 3. Trans-Aortic

Alternative Access (TEVAR) • • Common Illiac Direct aortic Axillary Trans-caval

Exposure

Percutaneous approach

Percutaneous Techniques • 6 -F sheath brachial or Femoral – Angiogram to direct puncture – Leave wire in place • • Snare with brachial-femoral access, 400 cm wire Balloon (8 x 40 mm) from the femoral or brachial Two 6 French proglides Additional Angioseal

Core Valve Pivotal Trial TAx vs TF • 202 Propensity matched patients in each group • No difference: – – – – 30 day all cause mortality (5. 4 vs 5. 9%) 1 year mortality (23. 3 vs 24. 8%) Stroke rate Re-intervention rates Major vascular complications Bleeding Gleason, presented at STS 2016 AKI Pacemaker rate

Meta-analysis: Catheter Cardiovasc Interv. Jan 2018. Amat-Santos et. Al. • 4504 patients (3, 886 TF and 618 TSc) • Similar baseline characteristics. • TSc group with higher logistic score and higher prevalence of CAD and PVD • Comparable 30 day mortality in the TSc group • No differences in: – – Procedural success 30 day stroke rate Major vascular complication 1 year mortality

Conclusion • • Axillary/Subclavian access is safe Easily accessed and controlled Usually free of disease Direct cannulation with pursestrings or percutaenous • Careful assessment with MSCT critical • TAVR results as good as TF