Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) requires multiple access sites, each with a potential risk of access site-related bleeding complications. While most bleeding events occur at the primary TAVI access site, a significant number of bleeding events originate from the secondary access sites. Additionally, a temporary pacing lead prevents early mobilization after TAVI, while prolonged immobilization is associated with an increased rate of post-procedural complications such as delirium and infection. Using alternative secondary access sites may reduce the incidence of access site-related complications and facilitate early mobilization after TAVI. This protocol describes an upper-extremity approach, as recently investigated in the TAVI XS trial, and aims to provide a comprehensive overview of the methodology. For this approach, the radial artery is used for diagnostic access, and the upper arm veins (basilic, cephalic, or brachial vein) are used for temporary pacing lead insertion. To enhance reproducibility, a step-by-step protocol was created on how to perform an upper-extremity secondary access approach during transfemoral TAVI. It was previously demonstrated that an upper-extremity approach for secondary access results in significantly fewer clinically relevant secondary access site-related bleeding complications. Additionally, the approach reduces the time to mobilization for patients who require a pacing lead for an extended period of time. Due to the pragmatic nature of the aforementioned study, the protocol presented here is readily applicable to the majority of transfemoral TAVI patients. The upper-extremity approach reduces periprocedural complications in TAVI patients and may facilitate early mobilization. The presented approach is the next step in minimizing the invasiveness of transfemoral TAVI and should be considered in all eligible TAVI patients.