Emerging Role of Large-bore Percutaneous Axillary Vascular Access: a Step-by-step Guide

Abstract

Advances in transcatheter structural heart interventions and temporary mechanical circulatory support have led to increased demand for alternative sites for large-bore vascular access. Percutaneous axillary artery access is an appealing alternative to femoral access in patients with peripheral arterial disease, obesity or for prolonged haemodynamic support where patient mobilisation may be valuable. In particular, axillary access for mechanical circulatory support allows for increased mobility while using the device, facilitating physical therapy and reducing morbidity associated with prolonged bed rest. This article outlines the basic approach to percutaneous axillary vascular access, including patient selection and procedure planning, anatomic axillary artery landmarks, access techniques, sheath removal and management of complications.

Percutaneous Axillary Artery Access for Lithoplasty of a Heavily Calcified Iliac Artery Chronic Total Occlusion

“…Percutaneous axillary access has been shown to be a reasonable alternative to brachial access for endovascular therapy of complex aortoiliac disease 1 given the high complication rate of the latter 2 and the better anatomical suitability for percutaneous axillary closure and bailout stenting. 3,4 A shallow angle of axillary needle entry is key 5 ; however, a longer than 7 cm micropuncture needle was not available here. Therefore, to reach the deep artery under a 5.5-cm pannus, the angle of entry had to be larger, possibly contributing to the lack of adequate hemostasis even after 2 closure devices.…”

Large‐bore arterial access in the era of structural cardiovascular disease

“…22 Axillary artery access is utilized as an alternative to standard femoral access in patients with iliofemoral peripheral arterial disease, obesity or when there is an expected device duration >24 to 48 hours. 23 A vessel diameter of ≥6 mm is recommended to ensure adequate distal perfusion for indwelling devices. 24 Trans axillary access has been used in TAVR (as an alternative access site) and for insertion of MCS devices which allows for increased mobility while the device is in place, facilitating physical therapy and reducing morbidity associated with prolonged bed rest.…”

“…Indeed, subclavian access is commonly used when iliofemoral access is deemed unsuitable 22 . Axillary artery access is utilized as an alternative to standard femoral access in patients with iliofemoral peripheral arterial disease, obesity or when there is an expected device duration >24 to 48 hours 23 . A vessel diameter of ≥6 mm is recommended to ensure adequate distal perfusion for indwelling devices 24 .…”

SCAI Position Statement on Best Practices for Percutaneous Axillary Arterial Access and Training

“…However, percutaneous axillary arterial access has become increasingly common and evolved from lessons learned from percutaneous access and closure of large-bore femoral arteriotomies. 4,5 Advantages of percutaneous access include avoidance of a surgical incision, general anesthesia, and conduit graft infection.…”