SCAI publishes recommendations for transaxillary arterial access
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The Society for Cardiovascular Angiography and Interventions published its recommendations for percutaneous placement of large-bore arterial sheaths and devices specifically via transaxillary arterial access.
The statement, published in the Journal of the Society for Cardiovascular Angiography & Interventions, was endorsed by the American College of Cardiology, the Heart Failure Society of America, the Society of Interventional Radiology and the Vascular & Endovascular Surgery Society.
The statement highlights specific anatomic considerations and risks associated with percutaneous axillary artery access as well as provides recommendations for best practices for access techniques, closure strategies and complication management.
“Axillary access is the predominant ‘alternative site’ for large-bore structural and endovascular procedures, and fortunately is less frequently affected by atherosclerosis. However, it is less muscular and more prone to injury than the femoral artery and potentially poses some unique risks to the unfamiliar operator,” Arnold H. Seto, MD, MPA, FSCAI, chief of cardiology at the Long Beach VA Medical Center in California, and writing group chair, said in a press release. “We brought together interventional cardiologists, vascular surgeons, interventional radiologists and heart failure specialists to share their best practices for this important technique, including anatomy, positioning, ultrasound guidance, dry closure and complication management.”
Best practice when choosing axillary access
The statement provides detailed recommendations for the best practice when choosing axillary access for large-bore transcatheter aortic valve replacement, endovascular aortic repair and mechanical circulatory support procedures. These recommendations extend to the multidisciplinary team, imaging modalities, vessel location and exit strategy.
The writing group suggested use of a multidisciplinary team that includes interventionalists experienced with large-bore access, vascular or cardiothoracic surgery services, cardiothoracic radiology and critical care nursing. In addition, HF or transplant specialists may be necessary for preprocedural planning and management of prolonged mechanical circulatory support.
“With the increasing use of percutaneous temporary mechanical circulatory support options for patients with cardiogenic shock, a wide range of specialists will need to be familiar with these concepts, including advanced heart failure, interventional cardiology, and cardiothoracic and vascular surgery,” David A. Baran, MD, FSCAI, system director of advanced HF, transplant and mechanical circulatory support at Cleveland Clinic’s Heart, Vascular & Thoracic Institute in Weston, Florida, and co-chair of the writing group, said in a press release.
The axillary artery is more fragile than the femoral artery and potentially more prone to complications such as bleeding, pseudoaneurysm, dissection, upper-extremity ischemia, thrombosis, infection, neurological complications and stroke.
Imaging modalities such as preprocedural CT are recommended to exclude tortuosity and atherosclerosis; however, these are not always possible for patients with acute or chronic kidney injury. Additionally, real-time ultrasound guidance may improve first-pass success rates, reduce vascular complications and facilitate accurate placement of transaxillary devices, according to the statement. Alternative access techniques, including placement of a guidewire used as a fluoroscopic target for needle puncture, may be considered.
The statement writing group also recommended access via the second segment of the axillary artery as the preferred site for puncture, regardless of left- or right-sided access.
Device removal should be planned out before placement, and factors to consider may include estimated dwell time, size of vascular catheter, stability of the patient and need for anticoagulation after device removal, according to the statement.
Future considerations and questions
“While there are no randomized trials comparing percutaneous axillary access with surgical axillary or other arterial access sites, the ongoing ARMS registry and the SUPER-AXA registry (NCT04589962) comparing surgical and percutaneous axillary access will continue to provide data on the safety and efficacy of percutaneous axillary access,” the committee wrote. “While the technique is demonstrably safe and effective at experienced centers, education and training on its unique anatomic and clinical challenges will ensure safe dissemination across the growing number of facilities performing such procedures.”
Please see the position statement for full details on the recommendations of the SCAI writing group.
Reference:
- SCAI Releases New Position Statement on Percutaneous Transaxillary Arterial Access and Training. Published April 19, 2022. Accessed April 19, 2022.
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