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Access Platform Techniques for Transcatheter Aortic Valve Replacement

Jacques Kpodonu, M.D. and Aidan A. Raney, M.D.

Hoag Heart Valve Center, Hoag Presbyterian Memorial Hospital, One Hoag drive, Newport Beach, California
ABSTRACT Background: One of the unique variables for successful implantation of transcatheter aortic valves involves the ability to secure an access route for deployment of the aortic valve. Aim of study: A large number of the high-risk patients with critical aortic stenosis referred for transcatheter valve implantation approach may not be candidates for the femoral approach due to peripheral vascular disease with the morbidity and mortality increased severalfold in patients who develop access related complications. Method & Results: A thorough knowledge and review of various alternate access site techniques and trouble shooting are therefore important and required by the implanting cardiac surgeons involved in transcatheter aortic valve therapy. Conclusion: The article review highlights the various percutaneous, hybrid, and surgical access techniques platforms available as well as options for implantation of these devices. doi: 10.1111/j.1540-

8191.2010.01041.x (J Card Surg 2010;25:373-380)

Aortic stenosis is a common valvular degenerative process in the adult population, with increased prevalence in advanced age. It is estimated that 300,000 patients have severe aortic stenosis in the United States, and approximately 60,000 undergo aortic valve replacement (AVR) every year. Within three years of the onset of angina, syncope, or congestive heart failure, 75% of patients die (2% per month mortality) unless treated with AVR. The three-year survival rates have been reported to be 87% and 21% for operated and nonoperated patients, respectively.1 Even in apparently asymptomatic patients, when the valve area is 0.8 cm2 or less, the mortality rate is high without AVR.2 The mortality rate for AVR is approximately 3% to 4% in the United States, but it increases with higher baseline risk factors, reaching 20% to 50% in the highest risk group of patients that may be considered inoperable.3 High surgical risk is dened as a calculated risk of mortality 15% using the Logistic EuroScore and or the Society of Thoracic Surgeons score risk of mortality 10%. Presence of comorbidities rendering conventional aortic valve surgery difcult, such as a porcelain aorta, previous cardiac surgery with presence of patent grafts, or severe adhesions, previous radiation therapy, liver cirrhosis, need to avoid sternotomy due to patient immobilization, or marked patient frailty tend to increase the calculated mortality risks. The introduction of a transcatheter option for AVR4-6 may provide a potential alternative solution for patients considered high risk for conventional surgical AVR. PATIENT SELECTION Selection of patients for transcatheter AVR requires a thorough assessment of the access vessel sites.7 Safe performance of transcatheter aortic valve procedures and other complex endovascular procedures for structural heart disease requires zero tolerance for major access-related complications. Thorough preoperative planning, understanding the pathology of aortoiliac occlusive disease, advanced endovascular skills, and ability to use alternate access sites including able to perform an iliac conduit via a retroperitoneal approach are necessary to achieve excellent results. Furthermore, deliverability of large sheath devices through tortuous anatomy or old graft material may be facilitated by more proximal access provided by construction of an iliac conduit. An evaluation of the iliac and common femoral arteries is important to make certain that these vessels will allow the delivery of sheaths ranging from 18 French (F) to 25 F. A minimum diameter of 9 mm (3 F approximately 1 mm) may be necessary for safe access via the common femoral arteries. A detailed quantitative angiogram and CT scan is required

Disclosure: None relating to manuscript. Address for correspondence: Jacques Kpodonu, M.D., Division of Cardiac Surgery and Endovascular Therapy, Hoag Heart and Vascular Institute, Hoag Presbyterian Memorial Hospital, One Hoag drive, Newport Beach, CA 96663. Fax: 949-650-1274; e-mail: jkpodonu@yahoo.com

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Figure 1. The Edwards Lifesciences Sapien aortic valve.

to analyze the diameter, tortuosity, and calcication of access vessels. Expect knowledge of the devices, access techniques, and bail-out maneuvers are necessary for a successful transcatheter aortic valve program. TRANSCATHETER AORTIC VALVE DEVICES The two frontrunners seeking to bring transcatheter aortic valves to market in the United States of America include (Carpentier-Edwards Lifesciences, Irvine, CA, USA) Sapien transcatheter aortic valve and the ReValving device (CoreValve Inc., Irvine, CA, USA). A thorough

knowledge of both devices and their deployment characteristics is essential for successful deployment of transcatheter aortic valves. The CoreValve prosthesis (CP) Figure 1 consists of a tri-leaet bioprosthetic porcine pericardial tissue valve, which is mounted and sutured in a self-expanding nitinol stent. The prosthetic frame/stent is manufactured by a laser-cutting tool and has an overall length of 50 mm. The lower portion of the prosthesis has highradial force to expand against the calcied leaets and to avoid recoil. The middle portion carries the valve and is constrained and narrower to avoid the coronary arteries, while the upper portion is ared to center and x the stent rmly in the ascending aorta and to provide longitudinal stability. The device is deployed via a delivery system into which the valve is loaded shortly before implantation. The CoreValve transcatheter valve is manufactured in two sizes, with the smaller prosthesis generally used for aortic annulus sizes 23 mm. The larger valve ts annulus sizes up to 27 mm in diameter. The sizes of the CoreValve delivery systems have been gradually reduced over time to allow easier deployment. Generally, the femoral artery is usually chosen for device placement due to the 18-F prole of the delivery catheter however alternate access sites including the axillary artery with a cutdown procedure is possible in cases of inadequate femoral access. The Sapien transcatheter aortic valve Figure 2 is composed of a balloon-expandable, stainless steel frame with an integrated tri-leaet bovine pericardial valve. The pericardial leaet material is treated with a similar process to the one used for the surgical CarpentierEdwards Perimount Magna pericardial valves (Thermax anticalcication treatment, leaet deection testing for matched elasticity, and proprietary tissue processing). The valve is available in two sizes (23 mm and 26 mm) to achieve optimal matching with the aortic annulus dimensions. The valve is crimped on a balloon just before implantation with a specially

Figure 2. The CoreValve transcatheter aortic valve system consists of pericardial leaets attached to a self-expanding nitinol frame. In the deployed state, the ared distal end assists in anchoring in the ascending aorta. The stent covers the coronary ostia, but cell size is designed to allow coronary artery perfusion and later coronary catheterization.

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designed mechanical crimper to achieve a symmetrical low prole and ensure retention onto the delivery system. The RetroFlex catheter delivery system has an 18-F shaft that increases in the distal end to 22 F or 24 F for the 23-mm and 26-mm valve, respectively. FEMORAL ACCESS TECHNIQUES FOR TRANSCATHETER AORTIC VALVE The most common percutaneous access sites for transcatheter aortic valve approaches are the femoral arteries. When choosing which site to access the vascular tree, one must not only consider the intended procedure but also the size of the sheath and distance to the pathology. The goal for percutaneous access is to create the smallest incision, which provides safe and effective entry, without creating vascular trauma. Sheaths up to 12 F (4.0 mm) can be safely placed percutaneously. Larger sheaths require a cutdown to ensure vascular hemostasis and minimize traumatic injury. PERCUTANEOUS RETROGRADE FEMORAL ARTERY TECHNIQUES Most right-handed physicians will prefer the patients right groin for femoral access, although both groins should be prepped in case of inaccessibility. After the pulse is identied, the inguinal ligament is found by tracing a line between the anterior iliac spine and the pubic tubercle. Often, especially in obese individuals, the inguinal crease is inferior to this landmark. Access should be made below the inguinal ligament corresponding to the common femoral artery. One will nd that if access is made too high, corresponding with the external iliac artery, hemostasis is difcult to achieve with manual pressure. In this case, hemorrhage can occur after removal of devices and a retroperitoneal hematoma can develop. This is often insidious in onset. In addition, the risk of pseudoaneurysm formation is higher in an external iliac stick, again because direct manual pressure cannot be applied this superiorly. A properly equipped endovascular suite will allow uoroscopic imaging of the groin to identify all anatomic landmarks. In addition to surface landmarks, most physicians use the medial half of the femoral head to guide femoral artery access; this ensures common femoral artery entry and avoids the complications of a higher stick. It is also useful in the pulseless femoral artery. Most vascular access kits include an 18-gauge straight angiographic entry needle. The needle is inserted using the dominant hand at a 45 angle while using the nondominant hand for guidance using a Seldinger technique. Percutaneous arterial femoral access is usually obtained by the Seldinger technique. A careful palpation of the femoral pulse is performed and a beveled needle (usually an 18 gauge) is introduced through the arterial wall. The needle is slowly withdrawn until the return of arterial blood is achieved signifying the intraluminal position of the needle. The presence of poor blood ow signies that the tip is misplaced or the needle is too close to the arterial wall.

A soft tip angled 0.035-inch guidewire is then introduced through the central lumen of the needle under uoroscopic guidance. Progress of the guidewire intraluminally should be monitored with uoroscopy to avoid diversion into branched vessels and dissection of the vessel. The presence of resistance in passing a guidewire signies possible misdirection or dissection of the vessel wall. In instances where the vessel may be small, calcied, or tortuous, a smaller access needle may be desirable. A micro-puncture kit (Cook, Inc., Bloomington, IN, USA) exists which includes a 21-gauge needle for initial access. Once access is achieved a small nick is made in the skin with a #11 blade and a dilator and an introducer sheath is then advanced over the glidewire with the dilator preceding the introducer sheath by a few inches again under uoroscopic visualization. Once the introducer sheath is positioned, the dilator is removed. A hemostatic valve at the end of the introducer sheath prevents leakage of blood. The introducer sheath permits various guidewires, balloons, and stents to be introduced safely within the arterial lumen. The introducer sheath can subsequently be upgraded to a larger delivery sheath for the deployment of an endograft. In patients with a femoral-to-femoral graft, percutaneous access can be performed either through the inow limb of the femoral-to-femoral graft or above the inow limb. OPEN RETROGRADE FEMORAL ACCESS TECHNIQUES The common femoral artery is usually exposed for retrograde cannulation and introduction of various large-sized introducer sheaths, balloons, selfexpandable and balloon-expandable stents, and endoluminal grafts. In an open retrograde approach, a curvilinear incision is made of two nger breaths above the groin crease and over the palpable femoral pulse. The incision is carried down to the femoral sheath. Retraction is performed with a Gelpe retractor or a Wietlander retractor. The femoral sheath is incised to expose the common femoral artery. Heavy silk sutures are passed circumferentially around the various side branches. Adequate mobilization of the common femoral artery is achieved to be able to achieve adequate proximal and distal control of the vessel. A Rummel tourniquet is applied to the common femoral artery to serve as a proximal control. The uoroscopic C arm is then positioned over the exposed femoral artery. Retrograde cannulation of the common femoral artery is then performed with a beveled needle (18 gauge) until pulsatile blood ow is visualized. A soft-angled tip guidewire is then advanced in the vessels under uoroscopy. The needle is then exchanged for a selected sized dilator and introducer sheath. The dilator is the removed and the sheath ashed with heperanized saline. Open cannulation or retrograde percutaneous access can be similarly performed in the contra lateral common femoral artery Figure 3A. Once the procedure is completed all wires and sheaths are removed under uoroscopic guidance to ensure that no injury is caused to the

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Figure 3. (A) Illustration demonstrating open retrograde cannulation of right common femoral artery and percutaneous retrograde access of left common femoral artery. (B) Illustration demonstrates closure of common femoral artery with a prolene stitch.

vessel wall. The arteriotomy is then closed with a 50 prolene suture after proximal and distal control is achieved Figure 3B. COMPLICATIONS FROM FEMORAL ACCESS TECHNIQUES Rupture Attempts to introduce a delivery sheath in a small, tortuous, calcied artery, or a combination will lead to rupture of the access vessel typically at the junction of the external and internal iliac artery or at the aortoiliac bifurcation. Rupture of an access vessel should be suspected, if there is a drop in the blood pressure

during advancement of the delivery sheath or during removal of the delivery sheath. The guidewire should be maintained at all times prior to removal of a delivery sheath, and an iliac angiogram was performed prior to removal of introducer sheaths to conrm extravasation of contrast Figure 4. Once rupture is conrmed, an appropriate covered stent length and diameter should be chosen and deployed across the area of rupture Figure 4B. In most instances, coverage of the hypogastric artery is required. Dissections Introduction of guidewires, introducer and delivery sheaths may result in dissection of the access vessels.

Figure 4. (A) Iliac angiogram of a patient who demonstrates rupture of the right external iliac artery. (B) A covered stent graft used to exclude site of rupture

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Similarly, balloon angioplasty of calcied access vessels may also result in a dissection ap of the resulting access vessels. Once a dissection is identied on angiogram, gentle balloon angioplasty may be performed to seal the dissecting septum or a covered or uncovered balloon deployable stent may be deployed to seal off the dissection. Failure to recognize a dissection may result in thrombosis of the access vessels with resulting ischemia of the involved lower extremity. RETROPERITONEAL ACCESS TECHNIQUES Patients with small, calcied, tortuous, or a combination of any of these factors may make femoral delivery of a transcatheter aortic valve device hazardous. Creation of a retroperitoneal conduit using a 10-mm graft allows such devices to be deployed safely without the risk of rupture or dissection of the femero iliac vessels. A retroperitoneal conduit is performed by making a 15cm semilunar right ank incision is made of four nger breaths above the groin crease. Division of the external oblique, internal oblique, and transversus abdominus muscle is performed in the direction of their bers. Extraperitoneal fascia and peritoneum are then retracted medially and dissection is carried out in the avascular plane of the retroperitoneum down to the level of the psoas muscle. All of the abdominal contents are then retracted medially with the help of a hand-held retractor or an Omni retractor providing excellent exposure of the lower infrarenal aorta, common iliac artery, and iliac bifurcation. The right common iliac artery along with the hypogastric and the external iliac artery are identied and mobilized. Care should be taken to spare the right urether that crosses the common iliac artery before diving deep into the pelvis. A Rummel tourniquet is applied to control the proximal common iliac artery, the external iliac artery, and origin of the hypogastric artery, alternatively vascular clamps could be

applied for control. Heparin is usually given to the patient prior to clamping the vessels. An arteriotomy is made on the common iliac artery with a #11 blade and extended with Potts scissors close to the bifurcation of the hypogastric artery and the external iliac artery. A 10-mm conduit is then sewn in an end-to-side fashion using 5-0 prolene suture Figure 5A. The 10-mm graft is subsequently tunneled through the retroperitoneal space beneath the inguinal ligament and brought out through the groin incision used to expose the common femoral artery. The graft is subsequently ashed and clamped at the groin incision with the Rummel tourniquets released from the common iliac artery, external iliac artery, and hypogastric artery. The 10-mm conduit is subsequently looped with a Rummel tourniquet and ready to be punctured with an 18-gauge needle for access and introduction of a guidewire and an introducer sheath. The introducer sheath is subsequently exchanged for a device sheath that is advanced into the distal aorta. The endoluminal graft is then introduced into the delivery sheath and deployed to the target area. Wires and sheaths are removed from the 10-mm conduit and the conduit is clamped. The conduit can either be trimmed to the appropriate length and the conduit tied off as a stump or the distal end of the conduit can be sewn to the more distal iliac system in an end-to-end fashion, as an interposition graft or more commonly the conduit can brought out tunneled to the groin by tunneling the conduit under the inguinal ligament and performing either an endto-end anastomosis or an ilio-femoral conduit. The iliofemoral conduit is performed by making an arteriotomy on the adequately exposed common femoral artery after adequate proximal and distal control is achieved. An end-to-side anastomosis is constructed with a 50 prolene suture with adequate ushing maneuvers performed prior to completion of the anastomosis. The ilio-femoral conduit is the best for patients who

Figure 5. (A) Illustration demonstrates a 10-mm retroperitoneal iliac conduit sewn to the common iliac artery. (B) Illustration demonstrates a direct iliac artery access with an introducer sheath through a retroperitoneal exposure.

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may require further intervention for diffuse thoracic aneurismal disease, as the conduit may be reused through a simple infrainguinal incision in the future. The groin incision is approximated in layers. The right ank incision is irrigated, a 10-F Jackson-Pratt drain is placed in the retroperitoneal space and the incision closed in layers. The same technique can be applied to the infrarenal aorta and thoracic aorta. Similarly, end-to-side grafting of a conduit to the axillary artery as described elsewhere to facilitate deep hypothermic circulatory arrest also provides excellent access to the thoracic aorta via the innominate. Alternatively, direct iliac artery access can be gained through a retroperitoneal approach. An 18-gauge needle is used to access the iliac artery followed by introduction of a guidewire and an introducer sheath (Fig. 5B). The introducer sheath is subsequently exchanged for a device sheath that is advanced into the distal aorta. The transcatheter valve can then be introduced into the delivery sheath and deployed to the target area. Wires and sheaths are removed and the arteriotomy repaired in a standard fashion. The ank incision is irrigated, a 10-F Jackson-Pratt drain is placed in the retroperitoneal space and the incision closed in layers. DEPLOYMENT OF AN ENDOCONDUIT IN SMALL CALCIFIED AND TORTUOUS ILIAC VESSEL An endoconduit is an alternative percutaneous technique that can be used to deliver a transcatheter aortic valve in a patient with a small, calcied, or tortuous vessel instead of the conventional ilio-femoral conduit.8 This technique can be applied in high-risk patients who have a relative contraindication to conventional open surgical techniques under general anesthesia. The endoluminal conduit technique allows aggressive balloon dilation of long segments of ilio-femoral stenosis without the risk of vessel rupture. The endoluminal graft conduit can be custom-assembled using grafts diameters of at least 8 mm and preferably 10 mm and can be

back-loaded into a delivery sheath and deployed via a femoral arteriotomy into the common iliac artery covering the origin of the internal iliac artery. Retrograde percutaneous access of the common femoral artery is performed with an 18-gauge needle in the usual fashion and a 0.035-inch glidewire is advanced under uoroscopic guidance into the distal thoracic aorta after heparin is administered. A 9-F sheath is then exchanged for the needle. A retrograde angiographic picture of the iliac vessels is performed noting the size, tortuosity, and calcication. The presence of a small, or severely calcic, or tortuous iliac vessel may preclude the introduction of a delivery sheath Figure 7A. An attempt may be made to pass the delivery sheath and if any resistance is noted the patient would require a retroperitoneal conduit or an endoconduit. Using the existing 9-F sheath, balloon angioplasty can be performed to gently dilate the vessel; subsequently an endoluminal graft, most commonly Viahbahn (W.L. Gore & Associates, Flagstaff, AZ, USA) endoluminal graft or an I-cast (Atrium) stent graft can be deployed across the common iliac and external iliac artery covering the hypogastric vessels Figure 6. Postdeployment balloon angioplasty is subsequently performed with a balloon to expand the endoluminal graft, this technique has been referred to as cracking and paving. The 9-F sheath is subsequently exchanged to a 20-F to 24-F delivery sheath that is required to deliver the thoracic endoluminal graft. VENTRICULAR APICAL APPROACH The transapical route is an option for patients with ilio-occlusive peripheral vascular disease in which a conduit is not indicated and may have some advantages with respect to ease of device positioning and implantation. During apical deployment of transcatheter valves the transverse aortic arch, which is thought to be a source of embolic stroke, is avoided; the working distance in the transapical approach is a much shorter

Figure 6. (A) Angiogram demonstrates a small, tortuous left iliac artery. (B) Illustration demonstrates deployment of an endoconduit for placement of a large access sheath.

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Figure 7. (A) Anterolateral thoracotomy through 5th and 6th interspace with (B) purse string attached for positioning of transapical valve sheath for aortic valve deployment.

and direct route that improves the accuracy of valve deployment. Antegrade passage of wires, catheters, and sheaths through the stenotic aortic valve also simplies the procedure. Some of the notable disadvantages of the transapical approach include pain from the thoracotomy site contributing to postoperative respiratory compromise and troublesome bleeding complications from the left ventricular apical site. Insertion of a femoral venous wire and an arterial 6-F sheath is strongly recommended to enable rapid cannulation for cardiopulmonary bypass using the Seldinger technique, if required.9 The transapical approach involves a left anterolateral mini-thoracotomy incision placed in the fth or possibly sixth intercostal space Figure 7. Use of a soft tissue retractor can optimize exposure and minimize rib spreading. The apex of the left ventricle may occasionally be palpated prior to skin incision. Evaluation of a preoperative CT scan addressing the relationship of the apex to the chest wall can help with the positioning of the incision. Straight access to the apex should be achieved, if the apex is not visualized, then the next intercostal space should be opened through the same skin incision. In general, it is better for the incision to be a bit low rather than too high, since the apex can be distracted downward with pericardial traction sutures. The pericardium is opened longitudinally and stay sutures allow for good exposure of the apex. The position of the left anterior descending coronary artery should be conrmed and noted. An epicardial pacing wire is placed and tested for pacemaker capture. Two apical purse-string sutures (2-0 prolene, large needle with ve interrupted Teon pledgets; Ethicon Inc. Somerville, NJ, USA) are placed with sufciently deep bites in the myocardium (approximately 3 mm to 5 mm, but not penetrating into the left ventricular cavity), close to the apex and lateral to the left anterior descending coronary artery. Care should be taken to ensure that adequate bites are taken of the muscle and not just the epicardial fat. Placement of the sutures in the bare spot just above the apex on the anterior wall can achieve this more reliably. Fluoroscopy is positioned to visualize the aortic root and the aortic annulus in a perpen-

dicular angle. All three aortic sinuses and aortic valve cusps should be in one plane. This is usually achieved using a left anterior oblique of approximately 10 and cranial approximately 10 position. The apex is punctured with a needle, and a soft guidewire is inserted antegrade across the stenotic aortic valve followed by a 14-F (30-cm long) soft tip sheath that is placed across the aortic valve. The procedural steps of transcatheter AVR are then carried out. After valve implantation, the apical sheath and guidewire are simultaneously retrieved. The apex is securely closed using the previously placed two purse-string sutures. Additional sutures may be required (usually with Teon reinforcement; Ethicon Inc.,) to achieve complete hemostasis. A nal shot of contrast is given into the aortic root to conrm valve function once the guidewire has been removed. Protamine is then administered in a standard dose. The pericardium is slightly closed to additionally cover the apex. A pleural chest tube or soft drain is inserted. Once all bleeding is controlled and a longacting local anesthetic is injected in the intercostals spaces, the chest wall and incision are closed in a routine fashion. Depending on local practice, the patient can be immediately extubated in the operating room or shortly thereafter upon transfer to the intensive care or postanesthetic care unit in the majority of cases. AXILLARY ARTERY ACCESS TECHNIQUES The axillary approach is simple and familiar to cardiac surgeons.10,11 The subclavian and proximal axillary arteries are usually good-sized vessels and are often free of atherosclerotic disease. This approach provided good stability of the sheath and valve delivery system, with what appeared to be simpler device positioning and implantation relative to the transfemoral approach. A patent left internal thoracic artery graft is probably a contraindication to a left axillary approach. The potential to compromise innominate artery ow is also a relative contraindication to the right axillary approach. The patient is placed in the standard supine position. For better exposure of the axillary artery, the arm is positioned near the body with the hand down to the side

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and the elbow slightly exed, almost as if the hand was placed in an imaginary pants pocket. Arterial pressure is monitored via arterial lines placed routinely in both radial. An infraclavicular skin incision 8 to 10 cm in length is made, running from a point just lateral to the sternal head of the clavicle to the upper deltopectoral groove. The pectoralis major fascia is incised and its bers split, exposing the axillary vein. The pectoralis minor is retracted laterally. The axillary artery is easily exposed under the vein and gently mobilized for 2 cm, without touching the medial and lateral cords of the brachial plexus. An umbilical tape is looped around the artery, and gentle traction is applied. After heparinization, the artery is cannulated either directly or indirectly through a longitudinal arteriotomy via a 10-mm woven Dacron graft anastomosed with 5 to 0 polypropylene suture after a side-bite clamp has been applied across the artery; this graft can then be used as the access site for transcatheter valve deployment. Use of the left axillary artery is preferred, as there is no occlusion of ow to the carotid arteries compared to use of the right axillary artery. CAROTID ARTERY ACCESS TECHNIQUES In rare instances, when a patient is not a candidate for a conventional ventricular apical approach and does not have suitable femoral arteries for access due to ilio-femoral vascular occlusive disease and the axillary artery is not available due to presence of a pacemaker or other device, a carotid artery approach can be performed as a last resort.12 In the carotid access technique, bilateral carotid arteries and the vertebrobasilar system is imaged to ensure that there is no evidence of extracranial occlusive disease and that there is good collateral ow in the circle of Willis. The common carotid artery is exposed in a routine fashion; heparin is given to the patient. The carotid artery is accessed with an 18gauge needle and a soft-angled glidewire is advanced into the ascending aorta and a short 6-F sheath introduced. Using an amplatzer catheter, the aortic valve is crossed with a 0.035-inch straight guidewire. The wire is then exchanged for a 6-F pigtail catheter. A pigtail catheter is placed above the aortic valve through a retrograde femoral approach. Once gradients are obtained the pigtail catheter in the ventricle is exchanged for a soft curved tip 0.035-inch stiff amplatz wire. The 6-F sheath is exchanged for the device sheath. The common carotid artery is clamped distally and the procedural steps for transcatheter aortic valve implantation are carried out. On completion of the procedure, the device is removed and the common carotid artery is repaired using traditional vascular closure techniques. The incision is closed in a routine fashion. This technique has been used to treat the rare patient with no peripheral access using the Medtronic CoreValve device and also to treat patients with thoracic aortic pathologies requiring an endovascular stent graft that could not be deployed by a conventional route. Complications that have arisen with this technique include retrograde type A dissection from using a long sheath instead of a short

sheath with the retrograde dissection requiring no surgical intervention. The metallic struts of the outow tract of the transcatheter valve apposes the false and true lumen together excluding any ow to the false lumen resulting in complete healing and resolution of the dissection at follow-up. The carotid access technique should not be performed without a complete circle of Willis to prevent potential strokes. CONCLUSION In conclusion with the development of new endovascular technology for structural heart disease, it is hoped that knowledge of the different approaches for deployment of transcatheter valves would lead to a larger number of patients considered high risk for traditional surgical aortic valves offered this new and exciting technology. The procedural learning curve is quite steep but as renement in devices, imaging technology, and acquisition of transcatheter skills by surgeons continues to improve transcatheter, AVR in the near future would be complimentary to open surgical AVR. REFERENCES
1. Schwarz F, Baumann P, Manthey J, et al: The effect of aortic valve replacement on survival. Circulation 1982;66(5):1105-1110. 2. Pai RG, Kapoor N, Bansal RC, et al: Malignant natural history of asymptomatic severe aortic stenosis: Benet of aortic valve replacement. Ann Thorac Surg 2006;82:21162122. 3. Walther T, Dewey T, Borger MA et al: Trans apical aortic valve implantation: Step by step. Ann Thorac Surg 2009;87(1):276-283. 4. Walther T, Falk V: Transcatheter aortic valve implantationshould we do it just because we can? Euro Intervention 2008;4(2):173-175. 5. Falk V, Schwammenthal EE, Kempfert J, et al: New anatomically oriented transapical aortic valve implantation. Ann Thorac Surg 2009;87(3):925-926. 6. Webb JG: Percutaneous aortic valve replacement will become a common treatment for aortic valve disease. J Am Coll Cardiol Interv 2008;1:122-126. 7. Diethrich EB, Ramaiah VG, Kpodonu J: Endovascular and hybrid management of the thoracic aorta. A case based approach. Dietrich 2008;1:54-58. 8. Kpodonu J, Rodriguez JA, Ramaiah VG, et al: Cracking and paving: A novel technique to deliver a thoracic endograft despite Ilio-femoral occlusive disease. J Card Surg 2009;24(2):188-190. 9. Walther T, Simon P, Dewey T, et al: Transapical minimally invasive aortic valve implantation: Multicenter experience. Circulation 2007;116(suppl 11):I240-I245. 10. Asgar AW, Mullen MJ, Delahunty N, et al: Trans catheter aortic valve intervention through the axillary artery for the treatment of severe aortic stenosis. J Thorac Cardiovasc Surg 2009;137(3):773-775. 11. Kokotsakis J, Lazopoulo G, Milonakis M, et al: Right axillary artery cannulation for surgical management of the hostile ascending aorta. Tex Heart Inst J 2005;32(2):189193. 12. Larrazabal R, Klurfan P, Sarma D, et al: Surgical exposure of the carotid artery for endovascular interventional procedures. Acta Neurochir (Wien) 2010;152(3):537-544.