Percutaneous Axillary Access: SCAI Calls for Best Practices

With growth in the use of percutaneous axillary arterial access in large-bore aortic valve interventions, endovascular aortic repair, and mechanical circulatory support (MCS) placement, it’s time to establish best practices, say the authors of a new position statement.

The document, released yesterday by the Society for Cardiovascular Angiography and Interventions (SCAI), has been endorsed by the American College of Cardiology, the Heart Failure Society of America, the Society of Interventional Radiology, and the Vascular & Endovascular Surgery Society. It was published in the Journal of the Society for Cardiovascular Angiography and Interventions.

“There’s increasing use of the transaxillary access as an alternative access, yet there’s no guidance statements put out for this,” Arnold H. Seto, MD (Long Beach VA Health Care System, CA), who chaired the document’s writing committee, told TCTMD. Most knowledge is anecdotal, formed from case series and experience rather than randomized studies, he said. “So this was felt to be a perfect opportunity to bring together a group of experts encompassing all these fields—heart failure specialists, interventional cardiologists, interventional radiologists, vascular surgeons, and of course cardiothoracic surgeons as well—to share our best practices in terms of accessing the axillary site.”

Seto said they’d been approached by industry asking if such guidance existed, since companies are developing technologies specific to axillary access. The growing interest in axillary comes at a time when the patient population is aging and the complexity of procedures is on the rise.

To further quality in this area, the SCAI position statement includes advice on everything from patient selection and contraindications to techniques for insertion, closure and device removal, and complication management.

Why Axillary?

While transfemoral access remains the most common access site for large-bore devices, this approach “may be limited in 13% to 20% of patients due to prior surgical interventions or severe aortoiliac and/or iliofemoral atherosclerotic disease, tortuosity, or calcification,” the position statement notes.

Axillary access has traditionally been done through open surgical incision and under general anesthesia. Percutaneous axillary arterial access, which has the advantage of avoiding these two aspects, as well as conduit graft infection, “has become increasingly common and evolved from lessons learned from percutaneous access and closure of large-bore femoral arteriotomies,” the statement authors explain.

Seto acknowledged that the literature still supports femoral as the predominant approach. “I don’t think anybody would favor the axillary approach over femoral,” he said. But in challenging cases where the femoral artery is hostile, and with the right expertise, axillary becomes more appealing. Other potential advantages for this access route include better mobility for patients, he noted. For instance, the Impella (Abiomed) percutaneous ventricular assist device can stay in place for up to a few weeks. There also appears to be a decreased risk of infection, Seto added.

As for potential downsides with axillary access, he said historically there has been concern about loss of arm function due to brachial plexus injury. Data from the Axillary Access Registry to Monitor Safety (ARMS) and other studies, though, suggest neurological complications are quite rare.

“Instead you just have the standard vascular access complications,” such as bleeding, pseudoaneurysm, and dissection, Seto noted. The axillary artery is “less muscular and therefore may be more prone to dissection,” he explained. This and the fact that these procedures occur near the lungs mean that operators must learn certain techniques.

A key message from the document, said Seto, is understanding and navigating the anatomy before and during the procedure. He highlighted several techniques, some perhaps lesser known:

• Abducting the arm to 45 to 90 degrees (to lessen vessel tortuosity)
• Puncturing the second segment of the axillary artery directly over the pectoralis minor (to avoid the anterior cords of the brachial plexus while allowing for manual compression over the second rib and surgical repair)
• Using a shallow angle of 25 to 30 degrees for needle entry (to increase access success and decrease the risks of sheath malformation and complications)
• Using micropuncture needles for access (to minimize trauma to adjacent tissues)
• Guiding procedures by ultrasound, selective angiography, or preferably both

Going forward, there also is the need to develop training requirements. The SCAI document stresses that these should be as universal as possible: “As percutaneous axillary access is a relatively new technique, training criteria and requirements should be developed that are applicable broadly to all interventionalists/specialties utilizing this approach.”

When it comes to hospital privileges, ultimately these are decided at an institutional level. Still, the authors say, standards “would ideally be the same for each specialty involved in percutaneous transaxillary procedures. In addition, requirements should be the same for operators in practice and those recently completing training.”

Team-Based Approach

The theme of collaboration, also highlighted in the document’s emphasis on multidisciplinary teams, was intentional, said Seto. “There was a lot of consensus considering the diversity of our [writing] group. . . . Everybody agreed on a lot of things.”

The only area that spurred substantial debate was “whether ultrasound guidance was mandatory or just recommended,” he added. Some of the authors believed fluoroscopy was sufficient, with angiography as needed, while others strongly favored ultrasound. In the end, the position statement took the “highly recommended but not mandatory” stance, said Seto.

“Real-time ultrasound guidance has been demonstrated across multiple access venous and arterial sites to improve first-pass success rates and reduce vascular complications. Familiarity with the technique will likely facilitate accurate placement of transaxillary devices,” the document specifies. “As the utility of ultrasound has not been confirmed for the axillary artery in randomized trials, however, alternative techniques of access, including placement of a guidewire in the axillary artery to serve as a fluoroscopic target for needle puncture, are reasonable.”