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CathMasters by CardioNerds

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Welcome to CardioNerds CathMasters, the podcast dedicated to advancing interventional cardiology through high-quality, evidence-based, and experience-driven education. Featuring leading experts from across the field, CathMasters democratizes access to practical interventional cardiology knowledge for fellows, early-career operators, and experienced proceduralists alike.

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July 10, 2026

9. Proctor Playbook — Percutaneous Transaxillary Access and Closure: State-of-the-Art Technique with Dr. Rajiv Tayal

<figure class="wp-block-post-featured-image"><img fetchpriority="high" width="1600" height="900" src="https://cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-—-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" style="object-fit:cover;" decoding="async" srcset="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?w=1600&ssl=1 1600w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?resize=300%2C169&ssl=1 300w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?resize=1024%2C576&ssl=1 1024w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?resize=768%2C432&ssl=1 768w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?resize=1536%2C864&ssl=1 1536w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?resize=800%2C450&ssl=1 800w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?resize=1200%2C675&ssl=1 1200w" sizes="(max-width: 1600px) 100vw, 1600px" data-attachment-id="378" data-permalink="https://cathmasters.com/9-proctor-playbook-percutaneous-transaxillary-access-and-closure-state-of-the-art-technique-with-dr-rajiv-tayal/9-proctor-playbook-percutaneous-transaxillary-access-and-closure-state-of-the-art-technique-with-dr-rajiv-tayal/" data-orig-file="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?fit=1600%2C900&ssl=1" data-orig-size="1600,900" data-comments-opened="1" data-image-meta="{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"0","alt":""}" data-image-title="9. Proctor Playbook — Percutaneous Transaxillary Access and Closure State-of-the-Art Technique with Dr. Rajiv Tayal" data-image-description="" data-image-caption="" data-large-file="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/9.-Proctor-Playbook-%E2%80%94-Percutaneous-Transaxillary-Access-and-Closure-State-of-the-Art-Technique-with-Dr.-Rajiv-Tayal.webp?fit=1024%2C576&ssl=1" /></figure> <div style="height:25px" aria-hidden="true" class="wp-block-spacer"></div> <p class="wp-block-paragraph">CathMasters Drs. <strong>Amit Goyal</strong>, <strong>Li Pang</strong>, and Dr. <strong>Nazli Okumus</strong>, discuss state-of-the-art percutaneous axillary arterial access and closure with expert proctor Dr. <strong>Raj Tayal</strong>. 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.</p> <p class="wp-block-paragraph">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.</p> <p class="wp-block-paragraph">CathMasters is for educational purposes only.</p> <p class="wp-block-paragraph">CathMasters is for educational purposes only. Music by <a href="https://pixabay.com/users/elijah_k-40677025/?utm_source=link-attribution&utm_medium=referral&utm_campaign=music&utm_content=186639">Elijah K</a> from <a href="https://pixabay.com/music//?utm_source=link-attribution&utm_medium=referral&utm_campaign=music&utm_content=186639">Pixabay</a></p> <h1 class="wp-block-heading">Pearls</h1> <ol class="wp-block-list"> <li><strong>Target the second segment of the axillary artery</strong> (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.</li> <li><strong>Arm abduction to 90° lengthens the second segment, brings the artery more superficially, and allows the operator to remain parallel to the vessel</strong> — reducing the tendency to splay the artery and cause occult bleeding beneath the pectoralis muscle.</li> <li><strong>The axillary artery has a thicker elastic lamina and a thinner muscular lamina than the femoral artery</strong>, 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.</li> <li><strong>Use an 0.018″ safety wire (not 0.014″)</strong> — 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.</li> <li><strong>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).</strong> Always have Viabahn stents in the room, not elsewhere!</li> </ol> <h1 class="wp-block-heading">Notes</h1> <p class="wp-block-paragraph"><strong>1. Pre-Procedural Planning: CTA Checklist and Screening</strong></p> <ul class="wp-block-list"> <li>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).</li> <li>Per the SCAI Position Statement, <strong>absolute contraindications</strong> include a prior covered stent or surgical repair that renders the artery unsuitable for percutaneous access. <strong>Relative contraindications</strong> include vessel calcification, stenosis, tortuosity, aneurysmal dilatation, or prior dissection.</li> <li>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.</li> <li>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.</li> </ul> <p class="wp-block-paragraph"><strong>2. Laterality Selection: Left vs. Right</strong></p> <ul class="wp-block-list"> <li><strong>Left axillary access is generally preferred</strong> 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.</li> <li><strong>Right axillary access</strong> 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.</li> <li>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.</li> <li>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.</li> </ul> <p class="wp-block-paragraph"><strong>3. Room Setup and Arm Positioning</strong></p> <ul class="wp-block-list"> <li><strong>Arm abduction to 90°</strong> 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.</li> <li>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.</li> <li>For <strong>left-sided access</strong>, move monitors to the head of the bed or foot of the patient (similar to pacemaker implant setup). For <strong>right-sided access</strong>, standard room configuration can be maintained.</li> </ul> <p class="wp-block-paragraph"><strong>4. Equipment Checklist</strong></p> <ul class="wp-block-list"> <li>Stiff micropuncture kit</li> <li>Ultrasound with linear probe and sterile cover</li> <li>Two Perclose devices (ProGlide or ProStyle)</li> <li>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)</li> <li>Pre-designated dry closure balloon: 8–10 × 40 mm compliant balloon (shorter balloons risk missing the arteriotomy)</li> <li><strong>Viabahn covered stents should be </strong><strong>in</strong><strong> the room</strong> — know the required sizes and sheath compatibility</li> <li>6F and 8F sheaths, JR4 or 3DR diagnostic catheter, stiff exchange-length 0.035″ wire for sheath insertion.</li> </ul> <p class="wp-block-paragraph"><strong>5. Sedation</strong></p> <ul class="wp-block-list"> <li>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.</li> <li>Experienced operators (≥10 cases) can achieve large-bore sheath insertion and Impella deployment in 7–10 minutes, comparable to transfemoral access times.</li> </ul> <p class="wp-block-paragraph"><strong>6. Axillary Artery Anatomy — Target Zone</strong></p> <ul class="wp-block-list"> <li>The axillary artery is divided into <strong>three segments</strong> relative to the pectoralis minor muscle: <ul class="wp-block-list"> <li><strong>1st segment</strong> (medial to pec minor): branch — superior thoracic artery</li> <li><strong>2nd segment</strong> (posterior to pec minor): branches — thoracoacromial artery, lateral thoracic artery</li> <li><strong>3rd segment</strong> (lateral to pec minor): branches — subscapular artery, anterior and posterior circumflex humeral arteries</li> </ul> </li> <li>The <strong>2nd segment is the recommended target</strong> 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).</li> <li><strong>Angiographic landmarks for the access zone</strong>: 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.</li> <li>The axillary artery typically measures 6–7 mm in diameter (range 5–8 mm).</li> </ul> <p class="wp-block-paragraph"><strong>7. Safety Wire Strategy</strong></p> <ul class="wp-block-list"> <li>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.</li> <li>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.</li> <li><strong>Wire entrapment risk</strong>: 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.</li> <li><strong>Critical</strong>: 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.</li> <li>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.</li> </ul> <p class="wp-block-paragraph"><strong>8. Ultrasound-Guided Puncture Technique</strong></p> <ul class="wp-block-list"> <li>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).</li> <li>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.</li> <li><strong>Angle of approach</strong>: 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 you advance to identify the needle position in subcutaneous tissue.</li> <li>Stay within the <strong>deltopectoral groove</strong> — if the vessel is deeper than ~5 cm, the puncture is likely too low on the anterior chest wall.</li> <li>Roadmap angiography is a useful backup tool but not routinely necessary for experienced operators.</li> </ul> <p class="wp-block-paragraph"><strong>9. Pre-Closure and Large-Bore Sheath Insertion</strong></p> <ul class="wp-block-list"> <li>After micropuncture access, insert a 6F sheath → pull back the 0.018″ wire → deploy two Perclose devices → upsize to 8F sheath → re-advance 0.018″ wire → advance JR4 over a 0.035″ J-wire into the ascending aorta → exchange for a stiff wire → insert large-bore sheath.</li> <li><strong>Tissue dissection</strong>: make a small nick, then use a Kelly/hemostat to bluntly dissect through the pectoralis muscle before advancing the Perclose. Watch the device go in during early cases — it can kink at the “elbow.”</li> <li><strong>Perclose orientation in the axillary artery</strong>: place sutures at <strong>11-and-1 o’clock or parallel at 12 o’clock</strong> rather than the traditional 10-and-2 o’clock used in the femoral artery. The axillary artery has more elastic lamina and less muscular lamina than the femoral, so aggressive suture tension at wide angles increases the risk of iatrogenic stenosis and “pull-through.”</li> </ul> <p class="wp-block-paragraph"><strong>10. Closure Device Selection</strong></p> <ul class="wp-block-list"> <li><strong>Perclose (suture-mediated VCD)</strong> is the device recommended by the SCAI Position Statement — it permits rewiring and maintenance of access if the device fails.</li> <li>Both ProGlide and ProStyle are acceptable. Collagen-plug devices (AngioSeal, Mynx, MANTA) do not allow preservation of access if they fail.</li> <li><strong>Hybrid closure</strong> (1 Perclose at 12 o’clock + 1 AngioSeal) is an advanced technique described by Dr. Tayal for experienced operators but is not recommended for early-experience cases given the greater risk of perclose failure with transaxillary access.</li> <li>VCD technical success in the axillary artery is ~85% overall, with a significant inverse relationship between sheath size and success (OR 0.87 per 1F increase).</li> </ul> <p class="wp-block-paragraph"><strong>11. Dry Closure Choreography and Bailout Algorithm</strong></p> <ul class="wp-block-list"> <li>From the femoral artery, advance a compliant balloon (8–10 × 40 mm, sized 1.0–1.1:1 to the artery) over the 0.035″ wire to a position proximal to the large-bore sheath tip, ideally distal to the vertebral artery.</li> <li><strong>Step-by-step</strong>: <ol class="wp-block-list"> <li>Inflate balloon to 2–4 atm → achieve endovascular hemostasis</li> <li>Walk the large-bore sheath out over the 0.035″ wire</li> <li>Pull and cinch the non-locking Perclose sutures</li> <li>Deflate balloon, pull back, and perform completion angiogram (can use Tuohy-Borst through the 0.035″ balloon catheter with the 0.018″ wire still in place)</li> <li>Obtain a <strong>DSA in a slightly caudal angulation</strong> to evaluate the underside of the vessel</li> </ol> </li> <li><strong>Bailout algorithm for persistent extravasation</strong>: <ol class="wp-block-list"> <li>Advance balloon to the arteriotomy site → inflate 2–4 atm + external manual pressure × 5 minutes → deflate → angiogram</li> <li>If still bleeding: repeat balloon tamponade × 5 minutes</li> <li>If still bleeding: administer <strong>protamine</strong> → repeat balloon tamponade × 5 minutes</li> <li>If still bleeding: proceed to <strong>covered stent</strong> (Viabahn preferred for superior apposition and crush resistance) or <strong>hybrid closure with AngioSeal</strong></li> </ol> </li> <li>Per the SCAI Position Statement, in cases of bleeding/extravasation, the balloon can be inflated at the arteriotomy site at 4–6 atm for 15–20 minutes with simultaneous manual compression and anticoagulation reversal.</li> </ul> <figure class="wp-block-image size-large is-resized"><img decoding="async" width="1024" height="742" src="https://cathmasters.com/wp-content/uploads/2026/07/image-1-1024x742.png" alt="" class="wp-image-382" style="width:624px;height:452px" srcset="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image-1.webp?resize=1024%2C742&ssl=1 1024w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image-1.webp?resize=300%2C217&ssl=1 300w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image-1.webp?resize=768%2C557&ssl=1 768w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image-1.webp?resize=1536%2C1113&ssl=1 1536w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image-1.webp?resize=1200%2C870&ssl=1 1200w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image-1.webp?w=1785&ssl=1 1785w" sizes="(max-width: 1024px) 100vw, 1024px" /></figure> <p class="wp-block-paragraph"><a href="https://pubmed.ncbi.nlm.nih.gov/41093448">Alternative Access for TAVR: A State-of-the-Art Review and Practical Guide.</a> JACC Cardiovasc Interv. October 12, 2025. </p> <figure class="wp-block-image size-full is-resized"><img decoding="async" width="600" height="701" src="https://cathmasters.com/wp-content/uploads/2026/07/image.webp" alt="" class="wp-image-381" style="width:600px;height:701px" srcset="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image.webp?w=600&ssl=1 600w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/image.webp?resize=257%2C300&ssl=1 257w" sizes="(max-width: 600px) 100vw, 600px" /></figure> <p class="wp-block-paragraph">Topography of the axillary artery.</p> <p class="wp-block-paragraph"><a href="https://onlinelibrary.wiley.com/doi/10.1155/2021/6393780">Topography and Anatomical Variations of the Axillary Artery.</a> Biomed Res Int. August 18, 2020.</p> <h1 class="wp-block-heading">References</h1> <ol class="wp-block-list"> <li>Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(3):100041. <a href="https://doi.org/10.1016/j.jscai.2022.100041">doi:10.1016/j.jscai.2022.100041</a> ⭐ <strong>Key Reference</strong></li> <li>Sherwood M, Allen KB, Dahle TG, et al. SCAI expert consensus statement on alternative access for transcatheter aortic valve replacement. J Soc Cardiovasc Angiogr Interv. 2025;4(3 Part A):102514. <a href="https://doi.org/10.1016/j.jscai.2024.102514">doi:10.1016/j.jscai.2024.102514</a> ⭐ <strong>Key Reference</strong></li> <li>Feistritzer HJ, Dumpies O, Rosseel L, et al. Alternative access for TAVR: a state-of-the-art review and practical guide. JACC Cardiovasc Interv. 2025;18(19):2309-2325. <a href="https://doi.org/10.1016/j.jcin.2025.08.029">doi:10.1016/j.jcin.2025.08.029</a> ⭐ <strong>Key Reference</strong></li> <li>Koziarz A, Kennedy SA, Awad El-Karim G, et al. Vascular closure devices for axillary artery access: a systematic review and meta-analysis. J Endovasc Ther. 2024;31(5):763-771. <a href="https://doi.org/10.1177/15266028221147451">doi:10.1177/15266028221147451</a></li> <li>Al Adas Z, Uceda D, Mazur A, et al. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg. 2024;79(3):487-496. <a href="https://pubmed.ncbi.nlm.nih.gov/37918698/">doi:10.1016/j.jvs.2023.10.048</a></li> <li>Schäfer U, Ho Y, Frerker C, et al. Direct percutaneous access technique for transaxillary transcatheter aortic valve implantation: “the Hamburg Sankt Georg approach.” JACC Cardiovasc Interv. 2012;5(5):477-486. <a href="https://doi.org/10.1016/j.jcin.2011.11.014">doi:10.1016/j.jcin.2011.11.014</a></li> <li>Palmerini T, Saia F, Kim WK, et al. Vascular access in patients with peripheral arterial disease undergoing TAVR: the Hostile Registry. JACC Cardiovasc Interv. 2023;16(4):396-411. <a href="https://doi.org/10.1016/j.jcin.2022.12.009">doi:10.1016/j.jcin.2022.12.009</a></li> <li>Lederman RJ, Babaliaros VC, Lisko JC, et al. Transcaval versus transaxillary TAVR in contemporary practice: a propensity-weighted analysis. JACC Cardiovasc Interv. 2022;15(9):965-975. <a href="https://doi.org/10.1016/j.jcin.2022.03.014">doi:10.1016/j.jcin.2022.03.014</a></li> <li>Kirker E, Korngold E, Hodson RW, et al. Transcarotid versus subclavian/axillary access for transcatheter aortic valve replacement with SAPIEN 3. Ann Thorac Surg. 2020;110(6):1900-1906. <a href="https://pubmed.ncbi.nlm.nih.gov/32712098/">doi:10.1016/j.athoracsur.2020.06.105</a></li> <li>van Wiechen MP, Tchétché D, Ooms JF, et al. Suture- or plug-based large-bore arteriotomy closure: a pilot randomized controlled trial. JACC Cardiovasc Interv. 2021;14(2):149-157. <a href="https://doi.org/10.1016/j.jcin.2020.09.052">doi:10.1016/j.jcin.2020.09.052</a></li> <li>Damluji AA, Tehrani B, Sinha SS, et al. Position statement on vascular access safety for percutaneous devices in AMI complicated by cardiogenic shock. JACC Cardiovasc Interv. 2022;15(20):2003-2019. <a href="https://doi.org/10.1016/j.jcin.2022.08.040">doi:10.1016/j.jcin.2022.08.040</a></li> <li>Yang K, Lee H, Choi IJ, et al. Topography and anatomical variations of the axillary artery. Biomed Res Int. 2020;2020:4657876. <a href="https://doi.org/10.1155/2020/4657876">doi:10.1155/2020/4657876</a></li> <li>Harris E, Warner CJ, Hnath JC, Sternbach Y, Darling RC. Percutaneous axillary artery access for endovascular interventions. J Vasc Surg. 2018;68(2):466-471. <a href="https://pubmed.ncbi.nlm.nih.gov/29398309/">doi:10.1016/j.jvs.2017.12.062</a></li> <li>Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous large-bore axillary access is a safe alternative to surgical approach: a systematic review. Catheter Cardiovasc Interv. 2020;96(7):1481-1488. <a href="https://doi.org/10.1002/ccd.29273">doi:10.1002/ccd.29273</a></li> <li>Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EuroIntervention. 2022;17(18):1514-1522. <a href="https://doi.org/10.4244/EIJ-D-21-00549">doi:10.4244/EIJ-D-21-00549</a></li> <li>Vegas A, Wells B, Braum P, et al. Guidelines for performing ultrasound-guided vascular cannulation: recommendations of the American Society of Echocardiography. J Am Soc Echocardiogr. 2025;38(2):57-91. <a href="https://doi.org/10.1016/j.echo.2024.12.004">doi:10.1016/j.echo.2024.12.004</a></li> <li>Flumignan RL, Trevisani VF, Lopes RD, et al. Ultrasound guidance for arterial (other than femoral) catheterisation in adults. Cochrane Database Syst Rev. 2021;10:CD013585. <a href="https://doi.org/10.1002/14651858.CD013585.pub2">doi:10.1002/14651858.CD013585.pub2</a></li> <li>Ooms JF, Van Mieghem NM. Completely percutaneous transaxillary aortic valve implantation under local anesthesia: a minimalist alternative access approach. JACC Cardiovasc Interv. 2019;12(1):e1-e2. <a href="https://doi.org/10.1016/j.jcin.2018.10.041">doi:10.1016/j.jcin.2018.10.041</a></li> <li>Bertoglio L, Conradi L, Howard DPJ, et al. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA Registry. J Vasc Surg. 2022;75(3):868-876.e3. <a href="https://doi.org/10.1016/j.jvs.2021.08.089">doi:10.1016/j.jvs.2021.08.089</a></li> <li>Gleason TG, Schindler JT, Hagberg RC, et al. Subclavian/axillary access for self-expanding transcatheter aortic valve replacement renders equivalent outcomes as transfemoral. Ann Thorac Surg. 2018;105(2):477-483. <a href="https://doi.org/10.1016/j.athoracsur.2017.07.017">doi:10.1016/j.athoracsur.2017.07.017</a></li> <li>Ali N, Cunnington MS, Muir D, et al. Transcatheter aortic valve implantation via percutaneous axillary access — a UK registry. Catheter Cardiovasc Interv. 2026;107(4):997-1004. <a href="https://doi.org/10.1002/ccd.70435">doi:10.1002/ccd.70435</a></li> <li>Fanaroff AC, Manandhar P, Holmes DR, et al. Peripheral artery disease and transcatheter aortic valve replacement outcomes: a report from the STS/ACC TVT Registry. Circ Cardiovasc Interv. 2017;10(10):e005456. <a href="https://doi.org/10.1161/CIRCINTERVENTIONS.117.005456">doi:10.1161/CIRCINTERVENTIONS.117.005456</a></li> </ol>

July 6, 2026

8. Data to Delivery: Percutaneous Transaxillary Arterial Access and Closure with Dr. Rajiv Tayal

<figure class="wp-block-post-featured-image"><img loading="lazy" width="1600" height="900" src="https://cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" style="object-fit:cover;" decoding="async" srcset="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?w=1600&ssl=1 1600w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?resize=300%2C169&ssl=1 300w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?resize=1024%2C576&ssl=1 1024w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?resize=768%2C432&ssl=1 768w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?resize=1536%2C864&ssl=1 1536w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?resize=800%2C450&ssl=1 800w" sizes="(max-width: 1600px) 100vw, 1600px" data-attachment-id="375" data-permalink="https://cathmasters.com/8-data-to-delivery-percutaneous-transaxillary-arterial-access-and-closure-with-dr-rajiv-tayal/data-to-delivery-percutaneous-transaxillary-access-and-closure/" data-orig-file="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?fit=1600%2C900&ssl=1" data-orig-size="1600,900" data-comments-opened="1" data-image-meta="{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"0","alt":""}" data-image-title="Data to Delivery Percutaneous Transaxillary Access and Closure" data-image-description="" data-image-caption="" data-large-file="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/Data-to-Delivery-Percutaneous-Transaxillary-Access-and-Closure.webp?fit=1024%2C576&ssl=1" /></figure> <div style="height:25px" aria-hidden="true" class="wp-block-spacer"></div> <p class="wp-block-paragraph">CathMasters hosts <strong>Dr. Amit Goyal</strong>, <strong>Dr. Li Pang</strong>, and <strong>Dr. Nazli Okumus</strong> discuss the evidence base for percutaneous transaxillary large-bore arterial access and closure with expert faculty <strong>Dr. Rajiv Tayal</strong>. 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. </p> <p class="wp-block-paragraph">CathMasters is for educational purposes only.</p> <p class="wp-block-paragraph">CathMasters is for educational purposes only. Music by <a href="https://pixabay.com/users/elijah_k-40677025/?utm_source=link-attribution&utm_medium=referral&utm_campaign=music&utm_content=186639">Elijah K</a> from <a href="https://pixabay.com/music//?utm_source=link-attribution&utm_medium=referral&utm_campaign=music&utm_content=186639">Pixabay</a></p> <h1 class="wp-block-heading">Pearls</h1> <ol class="wp-block-list"> <li><strong>The second segment of the axillary artery is the preferred access site</strong> 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).</li> <li><strong>“Bidirectional control is the fundamental principle of large-bore alternative access.”</strong> 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.</li> <li><strong>Stroke is the Achilles’ heel of transaxillary TAVR</strong> — 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.</li> <li><strong>More vascular complications ≠ more bleeding with percutaneous access.</strong> 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.</li> <li><strong>Axillary Impella enables early ambulation and device stability</strong> — 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.</li> </ol> <h1 class="wp-block-heading">Notes</h1> <p class="wp-block-paragraph"><strong>1. Why Transaxillary Access Matters Now</strong></p> <ul class="wp-block-list"> <li>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.</li> <li>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.</li> <li>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.</li> <li>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.</li> </ul> <p class="wp-block-paragraph"><strong>2. Outcomes: Transaxillary vs. Transfemoral TAVR</strong></p> <ul class="wp-block-list"> <li>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).</li> <li>Procedural success rates for transaxillary TAVR are high (91–100% across observational studies).</li> <li>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.</li> </ul> <p class="wp-block-paragraph"><strong>3. The Stroke Signal</strong></p> <ul class="wp-block-list"> <li>Stroke rates with transaxillary TAVR are consistently elevated at 6–8% across multiple registries: <ul class="wp-block-list"> <li>TVT Registry (Dahle et al.): 6.1% at 30 days with SAPIEN 3</li> <li>CoreValve Extreme Risk Pivotal Trial: 7.5%</li> <li>Hostile Registry (Palmerini et al.): 5.9% for transalternative access (92% transaxillary)</li> <li>ACCESS Study: 8.0% overall (4.0% debilitating)</li> </ul> </li> <li>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.</li> <li>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.</li> <li><strong>Laterality:</strong> 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.</li> <li>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%).</li> </ul> <p class="wp-block-paragraph"><strong>4. Vascular Complications: Percutaneous vs. Surgical Cutdown</strong></p> <ul class="wp-block-list"> <li>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.</li> <li>Southmayd et al. systematic review (2020): Percutaneous large-bore axillary access had dramatically less major bleeding than surgical cutdown (2.7% vs. 18%).</li> <li>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.</li> <li><strong>Dry closure</strong> 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.</li> <li>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.</li> </ul> <p class="wp-block-paragraph"><strong>5. Other Complications: Brachial Plexus Injury, Pneumo/Hemothorax</strong></p> <ul class="wp-block-list"> <li><strong>Brachial plexus injury</strong> 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.</li> <li>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.</li> <li><strong>Pneumo/hemothorax</strong> 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.</li> </ul> <p class="wp-block-paragraph"><strong>6. Transaxillary Mechanical Circulatory Support (MCS)</strong></p> <ul class="wp-block-list"> <li>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.</li> <li>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.</li> <li><strong>Dwell-time considerations:</strong> 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.</li> <li><strong>Device stability:</strong> 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.</li> <li><strong>Repositioning sheath:</strong> After removing the peel-away sheath (outer diameter ~17F for Impella CP), the repositioning sheath is 9F at the tip, increasing to 11–12F proximally. Leaving the peel-away sheath in place creates a 5–6F gap that promotes thrombus formation with risk of cerebral or distal embolization. Strategies to manage the downsized arteriotomy include: pulling down on the non-locking Perclose suture to snug the arteriotomy, circumferential injection of lidocaine with epinephrine to pucker the tissue, and figure-of-eight suture if needed.</li> </ul> <p class="wp-block-paragraph"><strong>7. Learning Curve and Training</strong></p> <ul class="wp-block-list"> <li>Al Adas et al. (2024): Prospective study of 146 patients undergoing percutaneous axillary access for complex endovascular aortic repair (FBEVAR). Covered stent rate was 6.9% overall, with a trend toward improvement (10% early cohort → 4% late cohort) and a significant negative correlation between cumulative complication rate and cumulative experience.</li> <li>Perclose device proficiency itself has a learning curve: data suggest ~45 cases for a vascular surgeon to achieve <5% failure rate; large-bore access increases this further. Across the US, even for large-bore femoral access without PAD, an average of 2.5 Perclose devices are used per case.</li> <li>SCAI recommends learning percutaneous axillary access through proctorship for at least the first 2–3 procedures, with operators prepared for bailout strategies.</li> <li>Training pathways include cadaveric courses for fellows transitioning to practice. No formal case-volume requirements have been established.</li> <li>The technique is transferable from basic femoral access skills and requires facility with ultrasound-guided access, micropuncture technique, and dry closure principles.</li> </ul> <p class="wp-block-paragraph"><strong>8. Axillary Artery Anatomy: Key Points</strong></p> <ul class="wp-block-list"> <li>The axillary artery is divided into three segments by the pectoralis minor muscle. Average diameter is approximately 6.2 mm (vs. ~8.5 mm for the femoral artery). Only 1–2% of patients have significant atherosclerotic disease in the axillary artery, even among those with severe iliofemoral PAD.</li> <li><strong>First segment</strong> (medial to pectoralis minor): Larger, more superficial, but proximity to the thoracic cavity increases pneumo/hemothorax risk. Difficult for surgical bailout.</li> <li><strong>Second segment</strong> (behind pectoralis minor): Preferred access site. Anterior surface is free of brachial plexus elements. Accessible for surgical repair. Compressible against the chest wall.</li> <li><strong>Third segment</strong> (lateral to pectoralis minor): Smallest portion. Surrounded by brachial plexus cords and enclosed in a fascial sheath with the artery and vein. Historical access site associated with high rates of nerve injury.</li> </ul> <p class="wp-block-paragraph"><strong>9. Is Transaxillary Access a Niche Skill or an Expanding Platform?</strong></p> <ul class="wp-block-list"> <li>Currently somewhat niche, but applications are expanding beyond TAVR to include: high-risk PCI with Impella support, cardiogenic shock with prolonged MCS, complex peripheral interventions (aortoiliac CTOs), EVAR/FBEVAR, and potentially ECMO.</li> <li>The technique evolved from small-bore peripheral interventions (6–8F) for aortoiliac CTOs, then graduated to intra-aortic balloon pumps, Impella CP, and eventually large-bore TAVR sheaths.</li> <li>Operators comfortable with axillary access gain a versatile platform applicable across multiple clinical scenarios, analogous to how comfort with tibial or popliteal access expands the peripheral interventionalist’s toolkit.</li> </ul> <h1 class="wp-block-heading">References</h1> <ol class="wp-block-list"> <li>⭐ Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(3):100041. doi:10.1016/j.jscai.2022.100041. <a href="https://doi.org/10.1016/j.jscai.2022.100041">Link</a></li> <li>⭐ Sherwood M, Allen KB, Dahle TG, et al. SCAI expert consensus statement on alternative access for transcatheter aortic valve replacement. J Soc Cardiovasc Angiogr Interv. 2025;4(3 Part A):102514. doi:10.1016/j.jscai.2024.102514. <a href="https://doi.org/10.1016/j.jscai.2024.102514">Link</a></li> <li>⭐ Feistritzer HJ, Dumpies O, Rosseel L, et al. Alternative access for TAVR: a state-of-the-art review and practical guide. JACC Cardiovasc Interv. 2025;18(19):2309-2325. doi:10.1016/j.jcin.2025.08.029. <a href="https://doi.org/10.1016/j.jcin.2025.08.029">Link</a></li> <li>⭐ Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EuroIntervention. 2022;17(18):1514-1522. doi:10.4244/EIJ-D-21-00549. <a href="https://doi.org/10.4244/EIJ-D-21-00549">Link</a></li> <li>⭐ Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous large-bore axillary access is a safe alternative to surgical approach: a systematic review. Catheter Cardiovasc Interv. 2020;96(7):1481-1488. doi:10.1002/ccd.29273. <a href="https://doi.org/10.1002/ccd.29273">Link</a></li> <li>⭐ McCabe JM, Kaki AA, Pinto DS, et al. Percutaneous axillary access for placement of microaxial ventricular support devices: the Axillary Access Registry to Monitor Safety (ARMS). Circ Cardiovasc Interv. 2021;14(1):e009351. doi:10.1161/CIRCINTERVENTIONS.120.009351. <a href="https://doi.org/10.1161/CIRCINTERVENTIONS.120.009351">Link</a></li> <li>⭐ Palmerini T, Saia F, Kim WK, et al. Vascular access in patients with peripheral arterial disease undergoing TAVR: the Hostile Registry. JACC Cardiovasc Interv. 2023;16(4):396-411. doi:10.1016/j.jcin.2022.12.009. <a href="https://doi.org/10.1016/j.jcin.2022.12.009">Link</a></li> <li>⭐ Lederman RJ, Babaliaros VC, Lisko JC, et al. Transcaval versus transaxillary TAVR in contemporary practice: a propensity-weighted analysis. JACC Cardiovasc Interv. 2022;15(9):965-975. doi:10.1016/j.jcin.2022.03.014. <a href="https://doi.org/10.1016/j.jcin.2022.03.014">Link</a></li> <li>Al Adas Z, Uceda D, Mazur A, et al. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg. 2024;79(3):487-496. doi:10.1016/j.jvs.2023.10.048. <a href="https://doi.org/10.1016/j.jvs.2023.10.048">Link</a></li> <li>Gleason TG, Schindler JT, Hagberg RC, et al. Subclavian/axillary access for self-expanding transcatheter aortic valve replacement renders equivalent outcomes as transfemoral. Ann Thorac Surg. 2018;105(2):477-483. doi:10.1016/j.athoracsur.2017.07.017. <a href="https://doi.org/10.1016/j.athoracsur.2017.07.017">Link</a></li> <li>⭐ Dahle TG, Kaneko T, McCabe JM. Outcomes following subclavian and axillary artery access for transcatheter aortic valve replacement: Society of the Thoracic Surgeons/American College of Cardiology TVT Registry report. JACC Cardiovasc Interv. 2019;12(7):662-672. doi:10.1016/j.jcin.2019.01.227. <a href="https://doi.org/10.1016/j.jcin.2019.01.227">Link</a></li> <li>Kindzelski B, Mick SL, Krishnaswamy A, et al. Evolution of alternative-access transcatheter aortic valve replacement. Ann Thorac Surg. 2021;112(6):1904-1911. doi:10.1016/j.athoracsur.2020.12.043. <a href="https://doi.org/10.1016/j.athoracsur.2020.12.043">Link</a></li> <li>Ali N, Cunnington MS, Muir D, et al. Transcatheter aortic valve implantation via percutaneous axillary access — a UK registry. Catheter Cardiovasc Interv. 2026;107(4):997-1004. doi:10.1002/ccd.70435. <a href="https://doi.org/10.1002/ccd.70435">Link</a></li> <li>Kaneko T, Hirji SA, Yazdchi F, et al. Association between peripheral versus central access for alternative access transcatheter aortic valve replacement and mortality and stroke. Circ Cardiovasc Interv. 2022;15(9):e011694. doi:10.1161/CIRCINTERVENTIONS.121.011694. <a href="https://doi.org/10.1161/CIRCINTERVENTIONS.121.011694">Link</a></li> <li>Koziarz A, Kennedy SA, Awad El-Karim G, et al. Vascular closure devices for axillary artery access: a systematic review and meta-analysis. J Endovasc Ther. 2024;31(5):763-771. doi:10.1177/15266028221147451. <a href="https://doi.org/10.1177/15266028221147451">Link</a></li> <li>Fanaroff AC, Manandhar P, Holmes DR, et al. Peripheral artery disease and transcatheter aortic valve replacement outcomes: a report from the STS/ACC Transcatheter Therapy Registry. Circ Cardiovasc Interv. 2017;10(10):e005456. doi:10.1161/CIRCINTERVENTIONS.117.005456. <a href="https://doi.org/10.1161/CIRCINTERVENTIONS.117.005456">Link</a></li> <li>Kaki A, Blank N, Alraies MC, et al. Axillary artery access for mechanical circulatory support devices in patients with prohibitive peripheral arterial disease presenting with cardiogenic shock. Am J Cardiol. 2019;123(10):1715-1720. doi:10.1016/j.amjcard.2019.02.038. <a href="https://doi.org/10.1016/j.amjcard.2019.02.038">Link</a></li> <li>Kajy M, Laktineh A, Blank N, et al. Deploying mechanical circulatory support via the axillary artery in cardiogenic shock and high-risk percutaneous coronary intervention. Am J Cardiol. 2020;128:127-133. doi:10.1016/j.amjcard.2020.04.055. <a href="https://doi.org/10.1016/j.amjcard.2020.04.055">Link</a></li> <li>Ooms JF, Van Mieghem NM. Completely percutaneous transaxillary aortic valve implantation under local anesthesia: a minimalist alternative access approach. JACC Cardiovasc Interv. 2019;12(1):e1-e2. doi:10.1016/j.jcin.2018.10.041. <a href="https://doi.org/10.1016/j.jcin.2018.10.041">Link</a></li> <li>Schäfer U, Ho Y, Frerker C, et al. Direct percutaneous access technique for transaxillary transcatheter aortic valve implantation: “the Hamburg Sankt Georg approach.” JACC Cardiovasc Interv. 2012;5(5):477-486. doi:10.1016/j.jcin.2011.11.014. <a href="https://doi.org/10.1016/j.jcin.2011.11.014">Link</a></li> <li>Bertoglio L, Conradi L, Howard DPJ, et al. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA Registry. J Vasc Surg. 2022;75(3):868-876.e3. doi:10.1016/j.jvs.2021.08.089. <a href="https://doi.org/10.1016/j.jvs.2021.08.089">Link</a></li> <li>Schultz J, Duval S, Shaffer A, et al. Axillary or subclavian Impella 5.0 support in cardiogenic shock: a systematic review and meta-analysis. ASAIO J. 2022;68(2):e29-e32. doi:10.1097/MAT.0000000000001637. <a href="https://doi.org/10.1097/MAT.0000000000001637">Link</a></li> <li>Bansal A, Kalra A, Kumar A, et al. Outcomes of combined transcatheter aortic valve replacement and peripheral vascular intervention in the United States. JACC Cardiovasc Interv. 2021;14(23):2572-2580. doi:10.1016/j.jcin.2021.08.024. <a href="https://doi.org/10.1016/j.jcin.2021.08.024">Link</a></li> </ol>

July 3, 2026

7. ACS Guidelines Question #2 with Dr. Michelle O’Donoghue

<figure class="wp-block-post-featured-image"><img loading="lazy" width="1397" height="1920" src="https://cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" style="object-fit:cover;" decoding="async" srcset="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?w=1397&ssl=1 1397w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?resize=218%2C300&ssl=1 218w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?resize=745%2C1024&ssl=1 745w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?resize=768%2C1056&ssl=1 768w, https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?resize=1117%2C1536&ssl=1 1117w" sizes="(max-width: 1397px) 100vw, 1397px" data-attachment-id="343" data-permalink="https://cathmasters.com/7-acs-guidelines-question-2-with-dr-michelle-odonoghue/7-acs-guidelines-question-2-with-dr-michelle-odonoghue/" data-orig-file="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?fit=1397%2C1920&ssl=1" data-orig-size="1397,1920" data-comments-opened="1" data-image-meta="{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"0","alt":""}" data-image-title="7. ACS Guidelines Question #2 with Dr. Michelle O’Donoghue" data-image-description="" data-image-caption="" data-large-file="https://i0.wp.com/cathmasters.com/wp-content/uploads/2026/07/7.-ACS-Guidelines-Question-2-with-Dr.-Michelle-ODonoghue.webp?fit=745%2C1024&ssl=1" /></figure> <div style="height:25px" aria-hidden="true" class="wp-block-spacer"></div> <p class="wp-block-paragraph">This episode is part of our comprehensive Decipher the Guidelines Series covering the <a href="https://www.cardionerds.com/2025-acsguidelines/">2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes</a>. </p> <p class="wp-block-paragraph">The following question refers to Section 5.2.1 of the 2025 ACS Guidelines.</p> <p class="wp-block-paragraph">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.</p> <p class="wp-block-paragraph">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.</p> <div style="height:30px" aria-hidden="true" class="wp-block-spacer"></div> <div class="wp-block-essential-blocks-toggle-content root-eb-toggle-3xjgh"> <div class="eb-parent-wrapper eb-parent-eb-toggle-3xjgh "> <div class="eb-toggle-3xjgh eb-toggle-wrapper switch-style-rounded eb-toggle-effect-default eb-toggle-primary" data-init-content="primary" data-size="m" data-switch-style="rounded" data-bg-type="solid" data-bg-color="#0693e3" data-bg-gradient="linear-gradient(45deg,#00F260,#0575E6)" data-primary-color="var(--eb-global-text-color)" data-secondary-color="var(--eb-global-text-color)" data-active-color="var(--eb-global-heading-color)"> <div class="eb-toggle-heading" style="display:none"><input type="checkbox" class="eb-text-switch-checkbox" id="eb-efa1cd99-1b4c-4e41-b202-a887a272bcf8" style="display:none"/></p> <div class="eb-text-switch-wrapper"> <div class="eb-text-switch-content" style="margin-left:auto;margin-right:auto"><label class="eb-text-switch-label" for="eb-efa1cd99-1b4c-4e41-b202-a887a272bcf8"></p> <div class="eb-text-switch-toggle"></div> <div class="eb-switch-names"> <div class="eb-switch-name primary"><span class="eb-toggle-primary-label-text">Question</span></div> <div class="eb-switch-name secondary"><span class="eb-toggle-secondary-label-text">Answer</span></div> </div> <p></label></div> </div> </div> <div class="eb-toggle-heading" style="display:block"><span class="eb-toggle-primary-label">Question</span><label class="eb-toggle-switch toggle-m"><input class="eb-toggle-input" type="checkbox"/><span class="eb-toggle-controller"></span><span class="eb-toggle-slider "></span></label><span class="eb-toggle-none eb-toggle-seperator"></span><span class="eb-toggle-secondary-label">Answer</span></div> <div class="eb-toggle-content"> <div class="wp-block-essential-blocks-wrapper root-eb-wrapper-bsgje"> <div class="eb-parent-wrapper eb-parent-eb-wrapper-bsgje "> <div class="eb-wrapper-outer eb-wrapper-bsgje"> <div class="eb-wrapper-inner"> <div class="eb-wrapper-inner-blocks eb-wrapper-align-center"> <figure class="wp-block-table"> <table class="has-fixed-layout"> <tbody> <tr> <td colspan="2">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 V<sub>2</sub>-V<sub>4</sub>. 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?</td> </tr> <tr> <td>A</td> <td>Proceed with primary PCI to LAD </td> </tr> <tr> <td>B</td> <td>Medical management with aspirin and enoxaparin </td> </tr> <tr> <td>C</td> <td>Medical management with aspirin and clopidogrel</td> </tr> <tr> <td>D</td> <td>Medical management with aspirin and ticagrelor</td> </tr> </tbody> </table> </figure> </div> </div> </div> </div> </div> <div class="wp-block-essential-blocks-wrapper root-eb-wrapper-fjs9w"> <div class="eb-parent-wrapper eb-parent-eb-wrapper-fjs9w "> <div class="eb-wrapper-outer eb-wrapper-fjs9w"> <div class="eb-wrapper-inner"> <div class="eb-wrapper-inner-blocks eb-wrapper-align-center"> <figure class="wp-block-table"> <table class="has-fixed-layout"> <tbody> <tr> <td>Explanation</td> <td colspan="2">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. </td> </tr> <tr> <td>Main Takeaway</td> <td colspan="2">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.</td> </tr> <tr> <td>Guideline Loc.</td> <td colspan="2">Section 5.2.1 </td> </tr> </tbody> </table> </figure> </div> </div> </div> </div> </div> </div> </div> </div> </div>

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