CathMasters by CardioNerds

In this AngioClub-style episode from the CardioNerds CathMasters, Drs. Amit Goyal, Nazli Okumus, Niko Spilias, and Grant Reed discuss transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) stenosis. Through a case of a 71-year-old man with severe aortic stenosis (AS), reduced left ventricular ejection fraction (LVEF), a recent heart failure hospitalization, and a heavily calcified Sievers type 1 BAV, the panel works through TAVR versus surgical aortic valve replacement (SAVR) selection, lifetime management, anatomic and procedural risk (paravalvular leak [PVL], permanent pacemaker [PPM], stroke, annular rupture), balloon/valve sizing, cerebral embolic protection (CEP), and expected LVEF recovery. The episode highlights that BAV is not itself a contraindication to TAVR but demands meticulous CT-based planning and phenotype-specific risk stratification.  CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Media Pearls BAV was excluded from the pivotal TAVR randomized trials — every comparison of TAVR vs SAVR in bicuspid anatomy comes from registries and observational cohorts, so shared decision-making and Heart Team review are essential.  “The more tricuspid-like the bicuspid valve behaves, the more predictable the TAVR.” Symmetric calcification and absence of a heavily calcified raphe/LVOT favor good outcomes.  The highest-risk BAV phenotype is a calcified raphe plus excess leaflet calcification — this combination tracks with roughly 3-fold higher 2-year mortality (~25.7%) and more aortic root injury and PVL; in general, avoid TAVR in these patients unless surgical risk is prohibitive.  “Perfection is the enemy of the good.” Accept mild PVL rather than aggressively post-dilating against a rock-hard calcified annulus, where chasing perfection risks annular rupture. A high mean gradient despite a low LVEF signals afterload-mediated dysfunction with reserve — these ventricles often recover after TAVR; about one-third of low-EF patients show early LVEF improvement, and very-low-EF/low-flow cohorts recover even more. Notes When is TAVR reasonable instead of SAVR in a bicuspid valve? SAVR remains first-line for truly young, low-risk BAV patients, particularly those <70–75 years, with aortopathy requiring repair, or with hostile annular/LVOT calcification.  BAV patients are increasingly encountered as TAVR expands to younger, lower-risk populations because bicuspid AS presents earlier — BAV represents ~50% of AS in younger patients and ~25% in those >80.  Registry and meta-analytic data show comparable short-term mortality but signals for higher stroke, PPM, PVL, and inferior long-term survival with TAVR vs SAVR in BAV; NOTION-2 showed a non-significant higher event rate with TAVR in the bicuspid subgroup (20.4% vs 7.8%).  The case patient’s low STS score (1.6%) underestimates true risk given severe mobility limitation, non-ischemic-appearing LV dysfunction, and a recent decompensated heart failure admission — factors not captured by STS-PROM that justified favoring TAVR after Heart Team discussion.  How does lifetime management inform the index procedure? Lifetime management aims to minimize the number of sternotomies and to sequence interventions (redo-TAVR, valve-in-valve, TAVR explant/SAVR) optimally over a patient’s remaining lifespan.  Guidelines favor SAVR in patients <70 years with low surgical risk and TAVR as primary therapy in patients ≥70 years with tricuspid anatomy suitable for transfemoral access; all other candidates warrant individualized Heart Team decisions.  Key lifetime-management inputs include age/life expectancy, aortopathy, coronary access for future procedures, annular dimensions/patient–prosthesis mismatch, likelihood of PPM, and feasibility of future valve-in-valve.  What are the anatomic and procedural risks specific to bicuspid TAVR? Principal risks: paravalvular leak (elliptical annulus, asymmetric sinuses, eccentric calcium), permanent pacemaker (especially right–left fusion pushing the frame toward the conduction system and with self-expanding valves), annular/root rupture, and stroke.  With new-generation devices, the historical gap in device success and PVL between BAV and tricuspid anatomy has narrowed substantially.  The highest-risk CT phenotype — calcified raphe plus excess leaflet calcification — is associated with higher aortic root injury (up to 4.5%), moderate/severe PVL (up to 6.5%), and ~25.7% 2-year mortality; this patient had excess leaflet calcification but a non-bulky raphe.  A prolonged baseline QRS (128 ms) plus right–left cusp fusion raises PPM concern; a high valve calcium score (>10,000 AU) plus internal carotid stenosis raises embolic concern.  How should the balloon and valve be sized in bicuspid anatomy? Predilation goals are crossability and, more importantly, circular, well-expanded valve deployment within the limits of the calcium; adequate expansion of a properly sized valve is increasingly linked to reduced HALT, lower gradients, and durability.  For heavily calcified BAV, size the balloon conservatively — often to the minimum annular diameter and adjusted down further for focal annular calcium — with a low threshold to post-dilate for expansion (not to chase trivial PVL).  Balloon-expandable valves apply more radial force and expand calcified annuli more reliably; self-expanding platforms rely more on adequate predilation and are now sized/predilated to the average diameter per contemporary guidance.  Beyond the virtual basal ring, assess for root tapering and intercommissural distance a few millimeters above the annulus; downsize if the supra-annular root is restrictive to avoid root injury.  When should cerebral embolic protection be used? The randomized PROTECTED TAVR trial found no statistically significant reduction in periprocedural stroke with CEP (2.3% vs 2.9%), though the confidence interval did not exclude benefit and disabling stroke was numerically lower (0.5% vs 1.3%).  Meta-analyses conflict: pooled randomized data (including PROTECTED TAVR and BHF PROTECT-TAVI) suggest no significant stroke reduction, whereas some analyses incorporating observational data report lower stroke.  Given the absence of a clear randomized benefit, use is individualized; a heavily calcified BAV with a very high calcium score, carotid disease, and planned predilation is a reasonable selective indication, though data does not strongly support this practice. What LVEF recovery can be expected after TAVR in low-EF AS? A high mean gradient (42 mm Hg here) despite LVEF 30–35% indicates predominantly afterload-mediated dysfunction with likely contractile reserve and favorable recovery potential.  Roughly one-third of high-/intermediate-risk patients with baseline LVEF <50% have early (≥10-point) LVEF improvement; low-flow/low-gradient patients with LVEF <30% show even larger absolute gains and outcomes independent of dobutamine contractile reserve.  Prior myocardial infarction, diabetes, coronary artery disease, and PPM are associated with reduced likelihood of LVEF recovery.  Case outcome mirrors this: LVEF rose to 40–45% by the next day and 55–60% at one month, with a mean gradient of 12 mm Hg, DVI 0.42, and only trace PVL. References Makkar RR, Yoon SH, Chakravarty T, et al. Association between transcatheter aortic valve replacement for bicuspid vs tricuspid aortic stenosis and mortality or stroke among patients at low surgical risk. JAMA. 2021;326(11):1034-1044. PubMed Yoon SH, Kim WK, Dhoble A, et al. Bicuspid aortic valve morphology and outcomes after transcatheter aortic valve replacement. J Am Coll Cardiol. 2020;76(9):1018-1030. PubMed Kapadia SR, Makkar R, Leon M, et al. Cerebral embolic protection during transcatheter aortic-valve replacement (PROTECTED TAVR). N Engl J Med. 2022;387(14):1253-1263. PubMed Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2025. PubMed Jørgensen TH, Savontaus M, Willemen Y, et al. Three-year follow-up of the NOTION-2 trial: TAVR versus SAVR to treat younger low-risk patients with tricuspid or bicuspid aortic stenosis. Circulation. 2025. PubMed Nagasaka T, Patel V, Shechter A, et al. Impact of balloon-expandable TAVR valve deformation and calcium distribution on outcomes in bicuspid aortic valve. JACC Cardiovasc Interv. 2024;17(17):2026-2038. PubMed Baman JR, Medhekar AN, Malaisrie SC, et al. Management challenges in patients younger than 65 years with severe aortic valve disease: a review. JAMA Cardiol. 2023;8(3):281-289. PubMed Liu J, Wei D, Wu Q, et al. Comparison of short- and long-term outcomes between transcatheter and surgical aortic valve replacement for bicuspid aortic valve stenosis: a systematic review and meta-analysis. Int J Surg. 2025. PubMed Mehaffey JH, Jagadeesan V, Kawsara M, et al. Transcatheter vs surgical aortic valve replacement in bicuspid aortic valves. Ann Thorac Surg. 2025. PubMed Beerkens FJ, Tang GHL, Kini AS, et al. Transcatheter aortic valve replacement beyond severe aortic stenosis: JACC state-of-the-art review. J Am Coll Cardiol. 2025;85(9):944-964. PubMed Gupta T, Malaisrie SC, Batchelor W, et al. Decision-making approach to the treatment of young and low-risk patients with aortic stenosis. JACC Cardiovasc Interv. 2024;17(21):2455-2471. PubMed Praz F, Beyersdorf F, Haugaa K, Prendergast B. Valvular heart disease: from mechanisms to management. Lancet. 2024;403(10436):1576-1589. PubMed Kolte D, Bhardwaj B, Lu M, et al. Association between early left ventricular ejection fraction improvement after transcatheter aortic valve replacement and 5-year clinical outcomes. JAMA Cardiol. 2022;7(9):934-944. PubMed Maes F, Lerakis S, Barbosa Ribeiro H, et al. Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction les

CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss bailout management for failed percutaneous axillary artery closure with expert Dr. Raj Tayal. Building on the Data-to-Delivery and Proctor Playbook episodes, this Crisis Control episode walks through a scenario of wide-open extravasation after Perclose failure during right axillary access TAVR. The team covers a stepwise escalation algorithm — from repeat Perclose deployment and serial balloon tamponade with protamine reversal, to hybrid closure with AngioSeal, to covered stent placement with the Viabahn endoprosthesis — and discusses when to call vascular surgery. This episode translates the 2022 SCAI Position Statement bailout recommendations into a practical, cath-lab-ready crisis management framework. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls As long as wire access is maintained across the arteriotomy, the operator retains full bailout capability — the working wire going through the arteriotomy allows for repeat vascular closure device attempt, including Perclose and/or AngioSeal (hybrid closure), while the safety wire positioned in the axillary artery from the secondary access allows for balloon tamponade and/or covered stent deployment. Losing wire access is the true crisis. If both Perclose sutures fail (snapped or cut), the “post-closure” rescue technique involves reinserting a large sheath, placing two 0.035″ wires side-by-side, removing the sheath, then inserting two 8F sheaths side-by-side for sequential Perclose deployment — maintaining wire access through the second sheath throughout. A 6Fr sheath will accommodate 5-7 mm Viabahn covered stents while a 7Fr sheath will accommodate up to a 9mm Viabahn covered stent. When deploying a covered stent from the radial artery without a destination sheath, use vascular markers on the screen to mark the bleeding site, lock the table position, and deploy based on those landmarks — retrograde contrast injection from the radial opacifies the vessel poorly compared to antegrade femoral injection. Covered stent placement in the 2nd segment of the axillary artery has minimal long-term sequelae — there are no critical branches that, if covered, would cause significant ischemia. Covering the lateral thoracic artery is acceptable; the subscapular artery is less desirable but tolerable. Avoid occluding the suprascapular artery (1st segment). Notes 1. Initial Assessment: Extravasation After Perclose Failure Bleeding is the most common complication of transaxillary access. Risk increases with larger sheaths, patient age, longer dwell time, tortuosity, urgency, and anticoagulation status. Hemostasis failure can lead to bleeding into the axillary space with possible brachial plexus compression and permanent nerve injury. As the axillary artery is extrathoracic, hemothorax should not occur if vessel puncture was in the correct location. The critical first question after failed closure: do you still have wire access through the arteriotomy and a safety wire in the artery? If yes, the full spectrum of bailout options remains available. 2. Stepwise Escalation Algorithm for Failed Closure The following algorithm represents a synthesis of the SCAI Position Statement recommendations and Dr. Tayal’s practical approach: Step 1 — Repeat Perclose: If one suture snapped but wire access is maintained, deploy an additional Perclose. This maintains wire access and allows interval assessment. If improvement is seen, proceed with observation. Step 2 — Serial balloon tamponade: Advance the tamponade balloon to the arteriotomy site (not proximal to it), inflate at 4–6 atm with simultaneous external manual compression × 5 minutes → deflate → angiogram. Repeat for a second 5-minute cycle if needed. Step 3 — Protamine reversal + balloon tamponade: Administer protamine, then repeat balloon tamponade × 5 minutes with external pressure. Thrombosis risk from protamine in an 8–10 mm axillary artery is low compared to coronary-sized vessels. Step 4 — Hybrid closure (AngioSeal): If bleeding is minimal and appears to be tract oozing between sutures, deploy an AngioSeal collagen plug. Although this sacrifices wire access through the axillary arteriotomy, the 0.018″ safety wire from the secondary femoral/radial access provides continued bailout capability. Step 5 — Covered stent: If bleeding persists after multiple tamponade cycles, proceed to covered stent deployment (see below). Step 6 — Surgical repair: Reserved for scenarios where covered stent is not feasible or effective (see below). 3. Post-Closure Rescue Technique (Both Percloses Failed) If both sutures are lost (snapped, cut, or pulled through), reinsert a large sheath (12–14F) to tamponade the arteriotomy. Place two 0.035″ wires through the sheath. Remove the sheath with both wires in place. Insert two 8F sheaths side-by-side, one over each wire. Deploy Perclose sequentially through one sheath while maintaining wire access through the other. If post-closure Perclose also fails, pivot to AngioSeal or covered stent via the second sheath. 4. Covered Stent Selection and Deployment Viabahn (W. L. Gore & Associates, Inc.) is the preferred covered stent for axillary artery bailout due to superior apposition and crush resistance in this mobile location. Self-expanding covered stents conform to the artery’s shape and adapt to the dynamic environment of the shoulder. Sizing: oversize by ≥1 mm relative to the artery diameter. For most patients (average axillary artery 6–6.5 mm), a 7 or 8 mm Viabahn covers the majority of cases. A 9 mm is rarely needed. Sheath compatibility: Viabahn 5–8 mm requires a 6–7F delivery system. Delivery route: Radial artery: A standard 6–7F slender sheath accommodates Viabahn up to 8 mm. However, visualization is limited (retrograde injection opacifies poorly). Use vascular markers on the screen to mark the bleeding site, lock the table, and deploy based on landmarks. The SCAI Position Statement recommends a long sheath from the radial approach, as passage of balloons and stents can induce spasm and entrapment. Femoral artery: Preferred for the first 5–10 cases — allows antegrade contrast injection with superior visualization and accommodates larger sheaths/devices. A 7–8F long (90–110 cm) sheath is recommended. Brachial artery: Avoid if possible; reserve for cases requiring stent sizes >8 mm when femoral access is unavailable. Length: Use a 50 mm stent and err on the side of extra length. Attempting to be too precise with a short stent risks needing additional stents proximally or distally. Post-dilation: Avoid if possible — post-dilating a self-expanding stent beyond its intended diameter causes foreshortening. Oversizing at initial deployment is preferable. Branch vessel considerations: In the 2nd segment, covering the lateral thoracic artery is acceptable. The subscapular artery (3rd segment) is less desirable to cover. The suprascapular artery (1st segment) should not be occluded. The vertebral and internal mammary arteries (subclavian) must be avoided, but these are normally far proximal from the access site in the 2nd axillary artery segment. Long-term outcomes: Covered stents in the axillary artery are well-tolerated with minimal long-term sequelae. The PAXA Registry reported secondary closure success in 98% of patients after adjunctive endovascular procedures (including 37 covered stents), with 100% axillary artery patency on follow-up CTA in the Al Adas et al. series. 5. When Covered Stent Is Not Feasible or Effective — Surgical Bailout Covered stent may be infeasible when: (1) the delivery system cannot be advanced (severe tortuosity, spasm), (2) the injury is too proximal (1st segment near the thoracic outlet), or (3) a mechanical complication prevents device extraction (e.g., partially deployed balloon-expandable TAVR valve trapped in the artery as referenced in the podcast episode). In the case described by Dr. Tayal, a balloon-expandable TAVR valve balloon ruptured on annular calcium, leaving a partially inflated valve that could not be fully deployed or withdrawn. The team pulled the device back into the axillary artery, inflated a proximal balloon to control bleeding, and a vascular surgeon performed a cutdown, extracted the device, placed a conduit, and the TAVR was completed successfully through the same artery. Key principle: if the arteriotomy is in the 2nd segment, proximal vascular control can be achieved endovascularly (balloon tamponade), buying time for surgical involvement without catastrophic hemorrhage. Direct surgical repair is preferable in some cases to avoid the risks of stent grafts (side branch occlusion, restenosis, thrombosis, infection, reduced mobility). In most cases, the arteriotomy can be repaired primarily unless there is significant atherosclerotic disease or vessel wall disruption, in which case patch angioplasty or interposition graft may be required. 6. Proactive Measures to Minimize Crisis Notify vascular surgery before the procedure — share the plan, data, and bailout strategy. Collegial pre-procedural communication prevents adversarial dynamics if complications arise. Have Viabahn stents (7 mm and 8 mm) in the room, not in a remote storage location. Experienced operators should achieve a <2–3% failure rate requiring covered stent or surgical conversion. The PAXA Registry reported a 1.5% open conversion rate, and the Al Adas et al. series reported a 6.9% covered stent rate (trending down to 4% in the late cohort with experience). Vascular complications from percutaneous transaxillary access, while reported at higher rates than transfemoral (up to 17% major vascular), do not appear to influence clinical outcomes when managed with proper endovascular techniques and materials. References Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial acce

CathMasters Drs. Amit Goyal, Li Pang, and Dr. Nazli Okumus, discuss state-of-the-art percutaneous axillary arterial access and closure with expert proctor Dr. Raj Tayal. Using a simulated case of Impella-supported high-risk PCI in a patient with severe bilateral iliofemoral PAD, the team walks through a step-by-step proctor playbook: pre-procedural CTA planning, laterality selection, room and arm setup, axillary artery anatomy, ultrasound-guided access technique, safety wire strategy, pre-closure with suture-mediated vascular closure devices, dry closure with balloon tamponade, and a bailout algorithm for failed hemostasis. This episode translates the 2022 SCAI Position Statement on Best Practices for Percutaneous Axillary Arterial Access into actionable, cath-lab-ready technique. Episode 8 reviews the evidence base for this technique in the “Data-to-Delivery” discussion and Episode 10 will tackle vascular complication management with transaxillary access in the “Crisis Control” discussion. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls Target the second segment of the axillary artery (posterior to pectoralis minor) — it is extrathoracic, has no critical branches in its course, is compressible against the chest wall, and carries the lowest risk of brachial plexus injury because no cord passes anterior to it. Arm abduction to 90° lengthens the second segment, brings the artery more superficially, and allows the operator to remain parallel to the vessel — reducing the tendency to splay the artery and cause occult bleeding beneath the pectoralis muscle. The axillary artery has a thicker elastic lamina and a thinner muscular lamina than the femoral artery, making it more susceptible to “pull-through” injury with excessive VCD suture tension. Dr. Tayal recommends placing the Perclose sutures at 11-and-1 o’clock (or parallel with both at 12 o’clock) rather than the traditional 10-and-2 o’clock to reduce the risk of iatrogenic stenosis. Use an 0.018″ safety wire (not 0.014″) — it provides sufficient support to deliver a Viabahn-covered stent if needed, and during dry closure, a 0.035″ balloon can be advanced over it, allowing a completion angiogram through a Tuohy-Borst valve without removing the wire. Dry closure bailout algorithm: inflate → 5 min hold with external pressure → deflate and angiogram → repeat if needed → give protamine and repeat → if still bleeding, proceed to covered stent or hybrid closure (AngioSeal). Always have Viabahn stents in the room, not elsewhere! Notes 1. Pre-Procedural Planning: CTA Checklist and Screening CTA is the gold standard for pre-procedural planning. Key assessments include: minimum luminal diameter (generally≥6 mm), calcification burden and distribution, tortuosity, aneurysmal disease, and relationship to branches (vertebral artery, IMA, lateral thoracic, subscapular). Per the SCAI Position Statement, absolute contraindications include a prior covered stent or surgical repair that renders the artery unsuitable for percutaneous access. Relative contraindications include vessel calcification, stenosis, tortuosity, aneurysmal dilatation, or prior dissection. When CTA is unavailable (e.g., AKI, emergent cases), ultrasound assessment of the axillary artery, with or without angiography, via an ipsilateral radial or femoral approach using a JR4 or 3DRC catheter, is a reasonable alternative. The axillary artery is infrequently affected by atherosclerosis (~2%), with disease most commonly located at the subclavian ostium. Note: CT scans are typically performed with the arms above the head, which can make vessels appear more tortuous or foreshortened than they are when the arms are abducted to 90° during the procedure. 2. Laterality Selection: Left vs. Right Left axillary access is generally preferred for TAVR due to more favorable delivery angles to the aortic valve (especially in older patients with type II/III aortic arches), avoidance of the brachiocephalic artery, and preservation of the innominate artery for cerebral embolic protection if needed. Right axillary access offers a simpler room setup (no need to flip screens or add a prep table) and may be reasonable in younger patients (type I arch) or for specific TAVR valve alignments. Stroke risk with transaxillary access is consistently elevated (~6–8%) regardless of laterality, valve type, or surgical vs. percutaneous approach. The Hostile Registry reported right-sided stroke rates nearly double those of left-sided (6.3% vs. 3.7%), though this did not reach statistical significance. Left-sided access increases operator radiation exposure. A left-sided pacemaker is not an absolute contraindication, but it may physically limit access; a shallow needle angle often allows successful placement. A patent LIMA graft is a relative contraindication — the degree of obstruction depends on vessel diameter at the IMA bifurcation compared with the planned sheath’s outer diameter. 3. Room Setup and Arm Positioning Arm abduction to 90° in a radial arm board is recommended. This lengthens the second segment of the axillary artery, brings it more superficial/anterior, and allows the operator to stay parallel with the vessel. Keeping the arm at the patient’s side (as in femoral access) creates a tendency to pull devices downward, splaying the artery and causing occult bleeding beneath the pectoralis muscle, which tracks down, along the lateral rib cage and may not be readily evident. For left-sided access, move monitors to the head of the bed or foot of the patient (similar to pacemaker implant setup). For right-sided access, standard room configuration can be maintained. 4. Equipment Checklist Stiff micropuncture kit Ultrasound with linear probe and sterile cover Two Perclose devices (ProGlide or ProStyle) 0.018″ wire (steelcore preferred; avoid V-18 due to risk of branch perforation with its high tip load; Dr. Tayal recommends avoiding 0.014″ wires due to insufficient support for covered stent delivery although some operators may prefer this) Pre-designated dry closure balloon: 8–10 × 40 mm compliant balloon (shorter balloons  risk missing the arteriotomy) Viabahn covered stents should be in the room — know the required sizes and sheath compatibility 6F and 8F sheaths, JR4 or 3DR diagnostic catheter, stiff exchange-length 0.035″ wire for sheath insertion. 5. Sedation Conscious sedation is the preferred approach for experienced operators and is standard at high-volume centers (including European practice). General anesthesia may be considered for early-experience cases or when a proctor is teaching. Experienced operators (≥10 cases) can achieve large-bore sheath insertion and Impella deployment in 7–10 minutes, comparable to transfemoral access times. 6. Axillary Artery Anatomy — Target Zone The axillary artery is divided into three segments relative to the pectoralis minor muscle: 1st segment (medial to pec minor): branch — superior thoracic artery 2nd segment (posterior to pec minor): branches — thoracoacromial artery, lateral thoracic artery 3rd segment (lateral to pec minor): branches — subscapular artery, anterior and posterior circumflex humeral arteries The 2nd segment is the recommended target for percutaneous access per the SCAI Position Statement, due to its extrathoracic location, absence of critical branches in the access path, compressibility against the chest wall, and decreased risk of brachial plexus injury (no cord passes anterior to this segment). Angiographic landmarks for the access zone: puncture between the lateral thoracic artery (first branch going straight caudally off the axillary artery outside the rib cage) and the subscapular artery (identifiable by its proximity to the circumflex humeral arteries near the humeral head). Staying between these two branches places the operator in the 2nd segment in ~95% of cases. The axillary artery typically measures 6–7 mm in diameter (range 5–8 mm). 7. Safety Wire Strategy For the first 5–10 cases, femoral access is strongly recommended as the source for the safety wire. Advance a JR4 or 3DR catheter to engage the subclavian, take a baseline angiogram, then advance an 0.018″ wire through the axillary artery. The 0.018″ wire in the artery serves dual purposes: (1) facilitates ultrasound-guided access by distinguishing artery from vein (important in patients with significant TR, where the vein may appear pulsatile and larger than the artery), and (2) provides a rail for bailout balloon/stent delivery. Wire entrapment risk: the 0.018″ wire can become entrapped in Perclose sutures. To mitigate this, pull back the 0.018″ wire before deploying pre-closure devices, then re-advance it after pre-closure through an 8F sheath. Critical: wire the 0.018″ past the arteriotomy site before inserting the large-bore sheath and maintain this wire in place — attempting to wire beyond the sheath after insertion risks dissection. During the procedure, the 0.018″ wire can remain alongside the coronary guide catheter in the femoral sheath (e.g., 0.018″ wire + 7F guide through an 8F sheath). Some oozing will occur but is not clinically significant. 8. Ultrasound-Guided Puncture Technique Use ultrasound to identify the brachial plexus (appears as a “ball of grapes” proximally; cords separate as the probe moves laterally — no cord anterior to the 2nd segment). Mark the skin: (1) where the 0.018″ wire is in the artery, (2) planned skin entry point, and (3) planned arteriotomy site (marked with an “X”). There should be a larger gap between skin entry and arteriotomy than expected based on a shallow angle of approach. Angle of approach: shallower than femoral access (~45°), generally ~30° for percutaneous transaxillary acces. A steep angle is a common beginner error — it makes the needle tip visible on ultrasound but creates a suboptimal arteriotomy. If the needle tip is hard to visualize, inject lidocaine as y

CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss the evidence base for percutaneous transaxillary large-bore arterial access and closure with expert faculty Dr. Rajiv Tayal. Approximately 5% of US TAVR cases require alternative access despite lower-profile devices, and with expanding indications for TAVR and mechanical circulatory support (MCS), the absolute number of patients needing non-femoral large-bore access is rising. This “Data to Delivery” episode reviews the comparative outcomes of transaxillary access for TAVR and MCS, the stroke signal and laterality debate, vascular complications of percutaneous versus surgical approaches, brachial plexus injury risk, dwell-time considerations for axillary MCS, and the learning curve for this technique.  CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls The second segment of the axillary artery is the preferred access site because it is devoid of brachial plexus elements on its anterior surface, is accessible to surgical bailout, and is distant enough from the chest cavity to minimize pneumo/hemothorax risk — a transpectoral approach through pectoralis minor under ultrasound guidance targets this segment (SCAI Position Statement, Seto et al. 2022). “Bidirectional control is the fundamental principle of large-bore alternative access.” Maintain a bailout wire (from the ipsilateral radial or femoral artery) in addition to the wire through the large-bore sheath. This enables proximal balloon tamponade (“dry closure”) and rapid covered stent deployment if catastrophic bleeding occurs. Stroke is the Achilles’ heel of transaxillary TAVR — rates are consistently 6–8% across registries (TVT Registry, Hostile Registry, ACCESS study) and appear independent of valve type, laterality, surgical vs. percutaneous approach, or center experience. The 2025 SCAI Consensus Statement notes that other extrathoracic access techniques (transcarotid, transcaval) should be favored over transaxillary when stroke risk is a primary concern. More vascular complications ≠ more bleeding with percutaneous access. The TVT Registry propensity match showed percutaneous transaxillary access had double the major vascular complications vs. surgical cutdown (3.0% vs. 1.5%), but Southmayd’s systematic review found dramatically less major bleeding with percutaneous access (2.7% vs. 18%). This paradox is partly definitional: covered stent placement counts as a vascular complication in percutaneous series but conduit/graft use does not in surgical series. Axillary Impella enables early ambulation and device stability — the ARMS Registry (102 patients, 10 centers) demonstrated feasibility with complication rates comparable to transfemoral Impella. Devices have been maintained for >14 days percutaneously, though prolonged dwell times increase thrombus risk and may warrant higher ACT targets. After removing the peel-away sheath, the repositioning sheath downsizes to 9F at the tip — leaving the peel-away sheath in place risks a 5–6F gap that promotes thrombus formation and embolization. Notes 1. Why Transaxillary Access Matters Now Approximately 25% of TAVR patients have peripheral arterial disease (PAD), and the 2025 SCAI Expert Consensus Statement reports that 4.7% of US TAVR cases require alternative (non-femoral) access despite lower-profile delivery systems. With TAVR expanding into lower-risk populations and MCS use increasing (high-risk PCI, cardiogenic shock), the absolute demand for non-femoral large-bore access is growing. Transaxillary access is versatile: it can be performed percutaneously under conscious sedation without general anesthesia or OR activation, and can be deployed emergently (e.g., cardiogenic shock) or electively. The 2025 SCAI Consensus Statement notes that transaxillary access may carry a higher risk for neurologic complications and recommends that other extrathoracic techniques be favored when feasible. 2. Outcomes: Transaxillary vs. Transfemoral TAVR Propensity-matched studies show comparable 30-day and 1-year mortality between transaxillary and transfemoral TAVR (Gleason et al., CoreValve trial; Dahle et al., TVT Registry; Kindzelski et al., Cleveland Clinic series). Procedural success rates for transaxillary TAVR are high (91–100% across observational studies). The transaxillary approach has emerged as the most common alternative to transfemoral access, surpassing transapical and transaortic routes, which carry higher mortality and bleeding rates. 3. The Stroke Signal Stroke rates with transaxillary TAVR are consistently elevated at 6–8% across multiple registries: TVT Registry (Dahle et al.): 6.1% at 30 days with SAPIEN 3 CoreValve Extreme Risk Pivotal Trial: 7.5% Hostile Registry (Palmerini et al.): 5.9% for transalternative access (92% transaxillary) ACCESS Study: 8.0% overall (4.0% debilitating) The 2025 SCAI Consensus concludes that elevated stroke rates appear to be a “class effect” of transaxillary access, independent of valve selection, laterality, surgical vs. percutaneous approach, or center experience. Proposed mechanisms include: (a) sheath-to-artery ratio effects in a smaller vessel (~6.2 mm average diameter vs. ~8.5 mm for femoral); (b) atherosclerotic embolization during catheter exchanges; (c) right-sided access crossing the innominate artery with inline flow to the right carotid; (d) vertebral artery flow interruption by the large-bore sheath. Laterality: In the Hostile Registry, right transaxillary stroke was 6.3% vs. 3.7% left, but this difference was not statistically significant (HR 1.14; 95% CI 0.37–3.57; p = 0.82). The ACCESS study similarly found no significant difference by laterality. Left-sided access is generally preferred when feasible, as the sheath may create a partial “embolic shield” across the brachiocephalic artery. Compared with transcarotid and transcaval access, transaxillary access has consistently higher stroke rates in propensity-matched analyses. Lederman et al. reported a five-fold reduction in stroke/TIA with transcaval vs. transaxillary access (2.9% vs. 13.2%). 4. Vascular Complications: Percutaneous vs. Surgical Cutdown TVT Registry propensity match (Chung et al., 2022; n = 4,219): Percutaneous transaxillary access had higher major vascular complications (3.0% vs. 1.5%; p = 0.02) but similar life-threatening bleeding (0.3% vs. 0.1%; p = 0.31) compared with surgical cutdown. Percutaneous access was associated with less ICU utilization and more use of conscious sedation. Southmayd et al. systematic review (2020): Percutaneous large-bore axillary access had dramatically less major bleeding than surgical cutdown (2.7% vs. 18%). The apparent paradox (more vascular complications but less bleeding) is partly definitional: covered stent placement is classified as a vascular complication in percutaneous series, whereas conduit/graft use in surgical cutdown is not. Dry closure is the key hemostasis strategy: deploy Perclose devices, and if there is residual bleeding, inflate a balloon proximal to the arteriotomy for tamponade while deploying a covered stent (Viabahn preferred for superior apposition and crush resistance). Covered stent patency in non-diseased axillary arteries is excellent long-term. The axillary artery has a rich collateral network (subscapular contributories); vascular surgery data suggest that ligation of the artery in the appropriate segment does not cause significant upper extremity ischemia. 5. Other Complications: Brachial Plexus Injury, Pneumo/Hemothorax Brachial plexus injury was historically the most feared complication (rates as high as 15–20% in the 1970s–80s) when access was obtained in the third segment of the artery (armpit, arm abducted, palpation-guided). The neurovascular bundle is enclosed in a fascial sheath with the artery and vein in this segment, making hematoma-related nerve compression common. Modern transpectoral access to the second segment under ultrasound guidance has dramatically reduced this risk. The anterior surface of the second segment is devoid of brachial plexus elements. In the ARMS Registry, 3 of 102 patients (2.9%) had brachial plexus symptoms (all C8 tingling), all occurring after multiple days of support. The Cleveland Clinic series (Kindzelski et al.) reported zero brachial plexus injuries. Pneumo/hemothorax risk increases with access too proximal (first segment), which approaches the thoracic cavity. The second segment is preferred in part because it is more readily accessible for surgical bailout than the first segment. 6. Transaxillary Mechanical Circulatory Support (MCS) The ARMS Registry (McCabe, Kaki, Tayal et al., 2021): 102 patients across 10 US centers underwent percutaneous axillary Impella CP placement. Successful implantation in 98%. Median device dwell time was 2 days (range 0–35 days). Procedural complications included 10 bleeding events and 1 stroke. Covered stent use was 17%, decreasing with operator experience. Duration of support was independently associated with a 1.1% increased odds of vascular complication per day. Indications for axillary MCS over femoral include: prohibitive iliofemoral PAD, anticipated need for support >24–48 hours, desire for early patient ambulation, and cardiogenic shock patients who may need escalation of support. Dwell-time considerations: Devices have been maintained percutaneously for >14 days (up to 30+ days in some cases). Prolonged dwell increases thrombus risk around the access site; higher ACT targets than transfemoral are recommended. Brachial plexus symptoms may increase slightly with prolonged dwell, likely from local inflammation or nuanced bleeding. Device stability: Axillary Impella tends to be more stable with less need for repositioning compared with femoral. Fixation technique: Foley locks to cross-hatch the cable across the patient’s chest with the controller positioned near the umbilicus. Reposition

This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.  The following question refers to Section 5.2.1 of the 2025 ACS Guidelines. The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by Henry Ford Interventional cardiology fellow and member of the CardioNerds Interventional Cardiology Council Dr. Li Pang, and then by expert faculty Dr. Michelle O’Donoghue. Dr. O’Donoghue is a cardiologist, senior investigator with the TIMI Study Group, and Associate Professor of Medicine at Harvard Medical School who holds the McGillycuddy-Logue Endowed Chair in Cardiology at Brigham and Women’s Hospital. She was the Vice Chair of the Writing Committee for the 2025 ACS Guidelines. Question Answer QuestionAnswer A 63-year-old woman presented to the emergency room for chest pain. She described having exertional chest pain for the past two months and had an episode of severe pain after dinner 3 days ago. She went to bed and slept it off.  She told her children today at a family gathering, and was immediately brought to the ED by her daughter. She has a history of hypertension and hyperlipidemia. She was asymptomatic and normotensive in the ED. Labs show a down-trending troponin and an elevated NT-proBNP but are otherwise unremarkable. Her ECG showed Q waves with ST elevation in V2-V4. She was treated with aspirin and heparin drip, and taken to the cath lab. Coronary angiogram showed complete proximal LAD occlusion with right-to-left collaterals, without significant residual disease elsewhere. She remains asymptomatic and is stable, both hemodynamically and electrically.What is the next best step with regard to reperfusion and anti-thrombotic management? A Proceed with primary PCI to LAD  B Medical management with aspirin and enoxaparin  C Medical management with aspirin and clopidogrel D Medical management with aspirin and ticagrelor Explanation The Correct answer is DIn patients who are stable with STEMI and have a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit. (Class 3, LOE B-R)The benefit of PPCI begins to diminish after >12 hours from symptom onset, but there appears to be continued benefit through approximately 24 hours. In stable asymptomatic patients with an occluded artery >48 hours after symptom onset, routine PCI has not been shown to be beneficial in the absence of ongoing ischemia. The relative utility of routine PCI for asymptomatic patients with STEMI between 24 and 48 hours from symptom onset is less rigorously tested.PCI is not recommended for an occluded infarct-related artery if the patient is asymptomatic and has a completed infarct. MACE outcomes were similar in those with an occluded infarct-related artery who underwent medical therapy versus those who underwent PCI 3 to 28 days after an MI (Occluded Artery Trial [OAT]), and results were no different at 7-year follow-up. Similar findings were noted in the DECOPI (Desobstruction Coronaire en Post-Infarctus) trial, which enrolled patients with an occluded artery and Q waves on the ECG presenting 2 to 15 days after symptom onset.However, coronary revascularization should be considered for patients with late presentations with continued signs and symptoms of ischemia, including cardiogenic shock, acute severe HF, persistent angina, and life-threatening arrhythmias.  Main Takeaway In patients who are stable with STEMI who have a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit. Guideline Loc. Section 5.2.1