Stenting for external outflow graft obstruction of a left ventricular assist device via a surgical axillary approach

External outflow graft obstruction is an uncommon late complication in patients supported with a fully magnetically levitated left ventricular assist device. Progressive extrinsic compression of the outflow graft can impair pump performance and lead to symptomatic deterioration, requiring intervention to restore graft patency. This video tutorial presents a hybrid procedure combining surgical transaxillary access with endovascular stent implantation for treatment of external outflow graft obstruction when transfemoral access is not feasible. A 72-year-old woman with ventricular assist device support presented with exertional dyspnoea. Imaging demonstrated a persistent external narrowing of the outflow graft distal to the cannula, and invasive assessment confirmed a significant pressure gradient. Severe kinking of the femoral vessels excluded conventional femoral access. After induction of general anaesthesia, the axillary artery was exposed through an infraclavicular incision and accessed under direct vision. A vascular sheath was introduced, allowing retrograde advancement of guidewires across the stenotic graft segment. Two overlapping balloon-expandable covered stents were deployed under fluoroscopic guidance to restore luminal diameter and antegrade flow. Completion angiography confirmed satisfactory stent expansion and improved device flow.