The role of the axillary artery as a second access choice in TAVI procedures

Abstract With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.

Comparison of femoral and axillary artery cannulation in acute type a aortic dissection surgery

Abstract Introduction: One of the most important points of the acute type A aortic dissection surgery is how to perform cannulation regarding cerebral protection concerns and the conditions of arterial structures as a pathophysiological consequence of the disease. Objective: In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations. Methods: The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results. Results: There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812). Conclusion: Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient's current medical condition or the surgeon's preference.

Innominate vs. axillary artery cannulation in aortic surgery: a systematic review and meta-analysis

Abstract Objective: To investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery. Methods: A comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017. Results: Only three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups. Conclusion: There is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.

Reparación de sección de arteria axilar por trauma vascular secundario a herida por arma blanca: a propósito de un caso / Repair of axillary artery section due to vascular trauma secondary to stab wounds: a case report

Objetivo: Presentar un caso clínico y discutir el manejo del trauma de arteria axilar y revisar la literatura actual. Caso Clínico: se presenta el caso de un paciente con lesión de arteria axilar, que es traído en shock hipovolémico al Servicio de Emergencias de nuestro hospital. En pabellón, se aprecia sección incompleta de la segunda porción de la arteria axilar. Se controla y repara con anastomosis primaria término-terminal. En su posoperatorio evoluciona de forma satisfactoria. Discusión: El manejo del trauma vascular debe ser metódico y multidisciplinario. Los signos duros de trauma vascular son indicación de exploración quirúrgica inmediata. Los pacientes con signos blandos pueden complementarse con imágenes. En una sección incompleta de arteria axilar, la anastomosis término-terminal ha mostrado buenos resultados. Conclusiones: las lesiones de arteria axilar en el contexto de traumas son infrecuentes. Su manejo necesita de un alto índice de sospecha, un enfoque multidisciplinario y un acceso quirúrgico adecuado al contexto.

Objective: To present a clinical case and discuss the management of axillary artery trauma and to review current literature. Clinical case: Male patient with axillary artery injury, who is brought in hypovolemic shock to the Emergency Department. Surgical findings demonstrated an incomplete section of the second portion of the axillary artery which was repaired with primary end-to-end anastomosis. Postoperatively, the patient evolves without pain and is discharged. Discussion: The management of vascular trauma should be methodical and multidisciplinary. Hard signs of vascular trauma mandate immediate surgical exploration. Patients with soft signs may need further evaluation with images. In an incomplete section of the axillary artery the end-to-end anastomosis has shown good results. Conclusions: Axillary artery lesions in the context of trauma are infrequent. Its management requires a high index of suspicion, a multidisciplinary approach and adequate surgical access.

Which Graft must be Preferred in Firearm Injury of the Axillary Artery.

Aims: Interposition graft technique is used mostly in firearm wounds of axillary artery, because of excessive defect of the vessel. Autologous vein has been preferred in general application, even though there is a mild size discrepancy between native artery and autologous vein. However, in many series, prosthetic graft infection risk has been reported as low. Presentation of Case: I am presenting a patient with a gunshot wound to the right upper chest. As a first choice I preferred saphenous vein which was occluded by thrombosis at the post-repair third week in spite of anticoagulant therapy and was replaced with prosthetic graft which was patent at the eight month follow-up. Discussion: Although the theoretical risk of infection of prosthetic grafts, many previous reports have demonstrated that prosthetic grafts are nearly as safe as autologous grafts and they have high long-term patency rate. Conclusion: There is no point in insisting on autologous grafts in cases of the diameter discrepancy between native artery and autologous graft, prosthetic graft may be used more frequently in axillary artery trauma, and post-repair anticoagulants may be administered in the consequences of size discrepancy between the native artery and the graft.

[Reporting the first case of subclavian-axillary artery thrombectomy using mechanical rotational thrombectomy method]

Arterial occlusions are divided as acute and chronic. Emboli is the most common cause of acute arterial occlusion, which is treated by perforating embolectomy using fogarty catheter. Some of these cases that are not diagnosed in early phase of the disease [within the first month], should be treated using open surgical techniques, since embolectomy via fogarty catheter is not effective in such instances. In this study we reported a 55 years old lady with subclavian-axillary artery occlusion who was suffered from critical limb ischemia. For the first time in Iran we used Rotator-Aspirer appreture for thrombectomy in this patient. Following the intervention, distal pulses were pulpated and ischemic signs and symptoms faded completely

Ligadura com algodäo e com granpos de titânio em artérias de cäes: estudo experimental em máquina simuladora de pressäo / Aterial titanium clip and stitch ligation in dogs: experimental study in a pump machine

O desenvolvimento da cirurgia video-laparoscópica trouxe a necessidade de tornar convencional a ligadura artérial com grampos de titânio para a diminuiçäo do tempo operatório. Com o objetivo de investigar e comparar a ligadura artérial com algodäo zero e com um, dois e três grampos de titânio, foram utilizadas 80 artérias de 20 cäes da espécie Canis Familiaris. De cada cäo, utilizaram-se as artérias axilares direita e esquerda e femorais direita e esquerda, que foram distribuídas em quatro grupos, mediante sorteio prévio e rodízio. Após a dissecçäo artérial e ligadura, as artérias foram submetidas a uma pressäo de 100 mmHg e de 300 mmHg, e a uma pulsaçäo de 70 batimentos por minuto, conseguida por meio de uma máquina simuladora da pressäo artérial. Houve extravasamento em três artérias, todas pertencentes ao grupo de ligadura com um grampo de titânio. Este extravasamento é estatisticamente significante e ocorreu em até 15 minutos após o início de funcionamento da máquina. Com os resultados, conclui-se que a ligadura artérial com um grampo de titânio tem maior probabilidade de extravasar do que a ligadura com dois ou três grampos de titânio, e a ligadura com fio de algodäo zero, em cäes. Näo há diferença entre a ligadura artérial com fio de algodäo e com dois ou três grampos de titânio, quando submetidas a pressäo de 300 mmHg e pulsação de 70 batimentos por minuto, em cäes.

Bypass axilocoronario como alternativa en la cirugía de revascularización miocárdica mínimamente invasiva / Minimally invasive direct coronary artery bypass with an axillo-left anterior descending vein graft

Con el fin de mantener los beneficios del bypass mamario-coronario a la arteria descendente anterior (DA), y a su vez reducir la invasividad propia de la cirugía con circulación extracorpórea, se están desarrollando algunas nuevas técnicas de cirugía de revascularización miocárdica mínimamente invasiva (CRMMI). Se presenta una nueva técnica de CRMMI realizada en un hombre de 74 años con cirugía coronaria previa en la cual se había usado la mamaria izquierda para realizar un puente a la diagonal. En la reoperación se confeccionó un puente desde la arteria axilar izquierda hasta la DA con vena safena para tratar una estenosis proximal de la DA después de una angioplastia fallida. La adecuada permeabilidad a los 10 meses permite concluir que el bypass axilo-coronario podría desarrollarse como una técnica alternativa de revascularización de la DA en reoperaciones con mamaria implantada previamente en otra coronaria, o cuando aquella no pudiera ser usada durante una CRMMI por toracotomía

Isquemia crítica por oclusión aortoilíaca: puentes aorto y axilofemorales / Critical ischemia by aortoiliac occlusion: aorto and axilofemoral by pass

Se realizó un análisis retrospectivo de los resultados del tratamiento quirúrgico de pacientes con isquemia crítica de miembros inferiores. Sólo se incluyeron aquellos casos en que se utilizaron puentes aortofemorales (Aof) y axilofemorales (Axf). Se revisaron los registros de 139 pacientes (59 puentes Aof y 97 Axf). Se excluyeron los pacientes con aneurismas, con cirugía vascular previa y los infectados. La decisión táctica se basó en las condiciones clínicas que suponían un riesgo operatorio elevado. La femoral superficial estaba ocluída en 129 casos (83 por ciento). Se utilizó siempre prótesis de dacron. La supervivencia global Aof: 68,02 por ciento (ES: 8,20); Axf: 43,07 por ciento (ES: 8,12); Permeabilidad primaria, Aof: 65,11 por ciento (ES: 9,32); Axf: 52,67 por ciento (ES: 9,32). Permeabilidad secundaria, Aof: 80,55 por ciento (ES: 7,57); Axf: 71,71 por ciento (ES: 8,75). Conservación miembro, Aof: 76,16 por ciento (ES: 8,11); Axf: 75,69 por ciento (ES: 8,56). Dentro de los primeros 90 días se realizaron puentes distales en el 5 por ciento de los casos por insuficiencia hemodinámica (3/59 Aof) y en el 6,18 por ciento por trombosis del injerto (6/97 Axf). Cuando no es factible realizar un estudio prospectivo por razones éticas, es posible utilizar controles históricos, aunque la información puede estar sometida a diferentes sesgos. Nuestra experiencia sugiere que: a) la permeabilidad secundaria de los puentes Axf obtenida mediante múltiples reoperaciones tiende a ser comparable a la permeabilidad primaria de los puentes aórticos y b) ambas tasas de conservación del miembro son similares

Puentes arteriales axilopoplíteos / Axilopopliteal arterial bypasses

Se presentan 5 puentes arteriales axilopoplíteos o distales, efectuados entre 1988 y 1993. Todos se colocaron para salvamento de extremidades gravemente isquémicas. En 3 de dichos casos existía ateromatosis extensa de las femorales común, superficial y profunda más fibrosis cicatricial en uno de ellos. En una instancia el puente fue secuencial, anclando la prótesis en un segmento de femoral común endarterectomizado y siguiendo de allí con vena safena in situ hasta poplítea distal, y los otros dos fueron directos con la prótesis hasta poplítea proximal. En dos ocasiones existió infección de prótesis axilofemorales previas, debiendo en un caso usarse la axilar contralateral como fuente de flujo, cruzando el pubis con la prótesis tubular de PTFE y llegando hasta la poplítea proximal, y en el otro, también usando la axilar contralateral pero llegando con el tubo PTFE hasta el puente femoroperoneo con safena in situ aún permeable. En ambos casos se retiro previamente el puente infectado. Un paciente falleció a los 9 meses por infarto al miocardio con su puente permeable, otro se amputó bajo rodilla por gangrena distal a los 37 meses, y los otros tres conservan su extremidad con un seguimiento entre 6 y 30 meses. Se concluye que pese a su longitud y tortuosidad, es un recurso para salvar extremidades isquémicas cuando otras operaciones anatómicas o extraanatómicas no son realizables

Axillopoliteal and aortopopliteal bypass two case reports

Two cases of aortopopliteal and axillopopliteal bypass grafts done for limb salvage are reported. These extra anatomical bypass grafts are valuable in patients who cannot otherwise undergo anatomical bypass grafts

Fístula arteriovenosa axilo-axilar: um método alternativo de acesso vascular para hemodiálise

Os autores relatam sua experiência com a criaçäo cirúrgica de fístula arteriovenosa entre os vasos axilares em sete pacientes renais crônicos, visando obter acesso vascular nestes indivíduos näo candidatos a transplante e dependentes de hemodiálise. Tal procedimento é recomendado quando outros meios de acesso já foram esgotados. Uma prótese tubular, aloplástica, em posiçäo pré-esternal, subcutânea, sem formar alça, conecta os vasos axilares. O método é de fácil realizaçäo cirúrgica e permite a obtençäo de um acesso vascular seguro, durável, bem tolerado, com morbidade desprezível e mortalidade nula

Revascularizaçäo atípica: derivaçöes axilo-poplíteas / Atypical revascularization: axillopopliteal derivations

Apresenta-se a experiência de 13 pontes axilopoplíteas indicadas para evitar área vascular infectada, ou por näo haver artéria femoral profunda adequada para revascularizaçäo. Dos 13 casos, 8 apresentavam artéria femoral profunda inadequada a 5 apresentavam infecçäo ingüinal de prótese prévia. No primeiro grupo, 50% dos pacientes mantiveram a derivaçäo pérvia por um período de 3 a 30 meses. No segundo grupo, de 5 pacientes, somente 2 näo tem a derivaçäo prévia (4 e 32 meses de seguimento). Os outros 3 casos, apesar de manterem os enxertos pérvios, desenvolveram infecçäo com conseqüente amputaçäo. Este procedimento infreqüente, deve ser considerado uma alternativa nas situaçöes de excessäo, que de outro modo levariam à amputaçäo do membro comprometido

Derivaçöes arteriais extra-anatômicas do segmento aorto-ilíaco: indicaçöes e resultados / Extra: anatomical bypass of the aorto-iliac segment: indications and results

As derivaçöes arteriais extra-anatômicas do segmento aorto-ilíaco constituem alternativas amplamente aceitas e bem padronizadas para revascularizaçäo dos membros inferiores, em pacientes com contra-indicaçäo para serem submetidos a procedimento padräo. Revascularizaçöes extra-anatômicas foram utilizadas em 76 pacientes. Em 26 foram implantadas derivaçöes femoro-femorais cruzadas; em 6 foram implantadas derivaçöes femoro-poplíteas cruzadas; 20 pacientes foram submetidos a derivaçöes axilo-femorais bilaterais e 4 a derivaçöes axilo-femorais unilaterais. As derivaçöes femoro-femorais cruzadas apresentaram índice de perviedade cumulativa de 55% a partir do 24§ mês até o 48§ mês de seguimento. Houve uma oclusäo precoce e outras 7 ocorreram tardiamente. As derivaçöes femoro-poplíteas cruzadas apresentaram perviedade cumulativa de 62% ao final dos 24 meses de seguimento. Os precários resultados desses tipos de derivaçäo provavelmente tenham ocorrido por inadequada avaliaçäo hemodinâmica da artéria ilíaca doadora. As derivaçöes axilo-femorais bilaterais demonstraram perviedade cumulativa de 61% ao final de 48 meses e as axilo-femorais unilaterais 37% ao final de 24 meses de seguimento. O melhor comportamento das primeiras em relaçäo às últimas se deve provavelmente pelas melhores condiçöes de vazäo. As derivaçöes arteriais extra-anatômicas do segmento aorto-ilíaco constituem alternativa importante para revascularizaçäo dos membros inferiores desde que consideradas as condiçöes hemodinâmicas do sistema arterial doador e receptor, e respeitadas condiçöes técnicas adequadas