CathMasters by CardioNerds

By CardioNerds

Welcome to CardioNerds CathMasters, the podcast dedicated to advancing interventional cardiology through high-quality, evidence-based, and experience-driven education. Featuring leading experts from a... more

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The podcast currently has 15 episodes available.

CathMasters by CardioNerds episodes:

September 19, 2026 14. ACS Guidelines Question #5 with Dr. Binita Shah
This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.
The following question refers to Section 4.3 of the 2025 ACS Guidelines.
The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by Cleveland Clinic interventional and structural cardiology fellow and member of the CardioNerds Interventional Cardiology Council Dr. Eunice Dugan, and then by expert faculty Dr. Binita Shah.
Dr. Binita Shah is an associate professor of medicine, interventional cardiologist, Director for research in Interventional Cardiology, and Director of the Department of Medicine Clinical Investigator Track at NYU. She is also an associate director of interventional cardiology and director of the transcatheter valve program at the VA New York Harbor Healthcare System. She was a member of the 2025 ACS Guidelines writing committee.
Question
Answer
QuestionAnswer
A 64-year-old woman with NSTE-ACS is taken to the cardiac catheterization laboratory. She is P2Y12 inhibitor-naive as she was unable to tolerate oral intake due to severe nausea and vomiting. Coronary angiography reveals a high-grade, thrombotic lesion in the mid-Right Coronary Artery. The interventionalist decides to initiate an intravenous P2Y12 inhibitor before proceeding with PCI. Which of the following is the most appropriate management strategy?
A
Administer Cangrelor as a 30 mcg/kg IV bolus followed by a 4 mcg/kg/min infusion for at least 2 hours or the duration of PCI, whichever is longer.
B
Administer Eptifibatide (GP IIb/IIIa inhibitor) as a routine double-bolus followed by an infusion to replace the need for P2Y12 inhibition.
C
Delay the procedure for 2 hours to allow for the administration and absorption of 600 mg of oral Clopidogrel.
D
Administer Cangrelor as a 180 mcg/kg bolus followed by a 2 mcg/kg/min infusion for exactly 1 hour.
Explanation
The correct answer is A.
Cangrelor is the only intravenous P2Y12 inhibitor currently available. It is a direct-acting, intravenous antagonist of the P2Y12 receptor characterized by rapid and potent platelet inhibitory effects, with restoration of platelet function occurring within 1 hour of drug discontinuation. It also has a very short half-life (3–6 minutes).Among patients with ACS undergoing PCI who have not received a P2Y12 inhibitor, intravenous cangrelor may be reasonable to reduce periprocedural ischemic events (Class 2B; LOE B-R).
Dosing Strategy:Bolus: 30mcg/kg IV bolus administered rapidly (under 1 minute) before PCI begins.Infusion: 4 mcg/kg/min IV infusion.Duration: The infusion must run for at least 2 hours or for the duration of the PCI, whichever is longer.
Transition to Oral Therapy:Ticagrelor: 180mg can be given at any time (during or after the infusion).Prasugrel/Clopidogrel: loading dose must be given immediately after the infusion is stopped. Giving these earlier can lead to a drug-drug interaction where the Cangrelor prevents the active metabolite from binding to the receptor.
In the CHAMPION PHOENIX trial, cangrelor was studied versus clopidogrel in patients undergoing PCI for acute or stable coronary syndromes. Cangrelor was administered as an intravenous bolus prior to PCI followed by an infusion for at least 2 hours or for the duration of the procedure, whichever was longer. In the control arm, clopidogrel was administered as a 600- or 300-mg loading dose immediately before or after PCI. At 48 hours, the primary endpoint of all- cause death, MI, ischemia-driven revascularization, or stent thrombosis was significantly reduced with cangrelor, with similar effects observed among those presenting with NSTE-ACS or STEMI.
Glycoprotein IIb/IIIa receptor inhibitors are parenterally administered drugs that block platelet aggregation by preventing platelet cross-linking via fibrinogen or von Willebrand factor binding to the glycoprotein IIb/IIIa receptor. Routine administration of GP IIb/IIIa inhibitors before PCI is not recommended and is associated with increased bleeding without improving ischemic outcomes. (Class 3 – No Benefit). Incurrent practice, the role of glycoprotein IIb/IIIa receptor inhibitors is largely limited to adjunctive use at the time of PCI in patients with large thrombus burden or as“rescue” or “bailout” therapy in patients with PCI complications such as no-reflow or persistent or recurring thrombus at the lesion.
B is incorrect. Routine “upstream” or periprocedural use of GP IIb/IIIa inhibitors (GPI) is Class 3 (No Benefit) for most patients. Large trials (like EARLY-ACS) showed that routine GPI use significantly increases major bleeding without a proportional decrease in ischemic events compared to modern P2Y12 inhibitors.
C is incorrect. In patients with NSTE-ACS or STEMI who are already in the lab, delaying the procedure to wait for oral drug absorption is not recommended.
D is incorrect. The correct bolus is 30mcg/kg. Cangrelor must be infused for at least 2 hours or the duration of the PCI, whichever is longer. Stopping at 1 hour would leave a “gap” in platelet inhibition before an oral agent can take effect. Because Cangrelor’s half-life is only 3–6 minutes, a premature stop increases the risk of acute stent thrombosis.
Main Takeaway
Cangrelor may be reasonable among patients with ACS undergoing PCI who have not received a P2Y12 inhibitor to reduce periprocedural ischemic events (Class 2b, LOE B-R).
Guideline Loc.
Section 4.3.3-4.3.4
...more
7min
September 18, 2026 13. ACS Guidelines Question #4 with Dr. Binita Shah
This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.
The following question refers to Sections 4.3.2 and 4.4 of the 2025 ACS Guidelines.
The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by University of Miami cardiology fellow and member of the CardioNerds Interventional Cardiology Council Dr. Saahil Jumkhawala, and then by expert faculty Dr. Binita Shah.
Dr. Binita Shah is an associate professor of medicine, interventional cardiologist, Director for research in Interventional Cardiology, and Director of the Department of Medicine Clinical Investigator Track at NYU. She is also an associate director of interventional cardiology and director of the transcatheter valve program at the VA New York Harbor Healthcare System. She was a member of the 2025 ACS Guidelines writing committee.
Question
Answer
QuestionAnswer
Q4- Oral P2Y12 Inhibitors during Hospitalization (4.3.2) and Parenteral Anticoagulation (4.4 9)
A 78-year-old man with a history of hypertension and controlled type 2 diabetes presents to a rural emergency department with 90 minutes of persistent, crushing, substernal chest pain. His ECG reveals 3-mm STE in leads V1 through V4. The nearest PCI-capable center is approximately 140 minutes away by ground transport, and air transport is unavailable due to weather. The patient refuses transfer to another facility for the duration of this admission. The clinical team decides to proceed with fibrinolytic therapy using weight-based Tenecteplase (TNK). Which of the following is the most appropriate initial antithrombotic regimen to accompany the fibrinolytic agent?
A
Clopidogrel 300 mg loading dose; Enoxaparin 30 mg IV bolus followed by 1.0 mg/kg SC every 12 hours.
B
Clopidogrel 75 mg (no loading dose); Enoxaparin 0.75 mg/kg SC every 12 hours (no IV bolus).
C
Ticagrelor 180 mg loading dose; Unfractionated heparin (UFH) weight-based IV bolus and infusion.
D
Prasugrel 10mg (no loading dose); Fondaparinux 2.5 mg IV bolus followed by 2.5 mg SC daily.
Explanation
The correct answer is B.
Clopidogrel is the only P2Y12 inhibitor with a Class 1 recommendation for use alongside fibrinolytic therapy to reduce death and MACE (Class 1, LOE A). Of note, pharmacodynamic variability in response to clopidogrel has been well described, and hyporesponders may be at increased risk of MACE and stent thrombosis when treated with clopidogrel after PCI. Other P2Y12 inhibitors such as ticagrelor and prasugrel are more potent than clopidogrel and achieve more rapid onset of inhibition of platelet activation but with increased risk of bleeding compared with clopidogrel.
When administered concurrently with fibrinolytic as the reperfusion strategy, clopidogrel is recommended to be administered with a loading dose (300 mg, then 75 mg daily) for patients <75 years of age and starting without a loading dose (75mg daily) for patients ≥75 years of age. In patients treated with a fibrinolytic agent who are undergoing subsequent PCI, either clopidogrel or ticagrelor (age<75 years, within 24 hours after a fibrinolytic agent) or prasugrel (>24 hours after a fibrinolytic agent) are alternatives to support PCI.
Parenteral anticoagulation is recommended for all patients with ACS, irrespective of the initial treatment strategy, to treat the underlying pathophysiologic process (coronary atherothrombosis) and reduce the risk of recurrent MACE. The choice of a parenteral anticoagulant can be complex because it is influenced by various factors, including vascular access site, renal function, and concomitant use of other antiplatelet or anticoagulant agents. In patients with STEMI treated with fibrinolytictherapy, parenteral anticoagulation is recommended before and after fibrinolytic therapy to reduce ischemic events.
In patients with STEMI who received fibrinolytic therapy and who are not planned for an invasive approach (as with the patient in the question stem), enoxaparin is the preferred anticoagulant over UFH. In the ExTRACT-TIMI 25 study, enoxaparin until hospital discharge or for a maximum of 8 days (whichever came first) was compared with UFH administered for at least 48 hours. The primary endpoint of death or nonfatal recurrent MI through 30 days occurred in 12% in the UFH group compared with 9.9% in the enoxaparin group. In a meta-analysis of 14 randomized trials, UFH did not reduce reinfarction or death in patients treated with fibrinolytic therapy. In contrast, low-molecular- weight heparin reduced the risk of reinfarction and death compared with placebo and the risk of reinfarction.
In patients >75 years of age, the dosing must be modified: Omit the initial 30 mg IV bolus. Reduce the subcutaneous dose to 0.75 mg/kg (instead of the standard 1.0 mg/kg). The first two SC doses should also be capped at a maximum of 75 mg each.
After receiving the fibrinolytic and adjusted antithrombotics, the patient should be transferred to a PCI center to facilitate immediate or early catheterization depending on the clinical circumstances, if this is in-line with the patient’s wishes. Hospitals should have transfer protocols in place to allow for a seamless transfer to the PCI-capable facility as soon as it is safe to do so. A detailed assessment of clinical status is critical to determine the timing of angiography.
A is incorrect: This is the standard dose for patients under 75 years of age. In a 78-year-old, the IV bolus of Enoxaparin and the Clopidogrel load significantly increase the risk of a fatal brain bleed.
B is incorrect: Ticagrelor is not recommended as an adjunct to fibrinolysis in the 2025 ACS guidelines.
D is incorrect: While fondaparinux may be used alongside lytic therapy when not planning an invasive strategy, prasugrel does not have a Class 1 recommendation for use with fibrinolytic therapy.
Main Takeaway
– Clopidogrel is the only P2Y12 inhibitor with a Class 1 recommendation for use alongside fibrinolytic therapy
Guideline Loc.
Sections 4.3.2 and 4.4 Table 10
...more
6min
September 18, 2026 12. ACS Guidelines Question #3 with Dr. Binita Shah
This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.
The following question refers to Section 3.2 of the 2025 ACS Guidelines.
The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by Cleveland Clinic interventional and structural cardiology fellow and member of the CardioNerds Interventional Cardiology Council Dr. Eunice Dugan, and then by expert faculty Dr. Binita Shah.
Dr. Binita Shah is an associate professor of medicine, interventional cardiologist, Director for research in Interventional Cardiology, and Director of the Department of Medicine Clinical Investigator Track at NYU. She is also an associate director of interventional cardiology and director of the transcatheter valve program at the VA New York Harbor Healthcare System. She was a member of the 2025 ACS Guidelines writing committee.
Question
Answer
QuestionAnswer
A 55-year-old woman is brought to the Emergency Department after an out-of-hospital cardiac arrest. She had a witnessed collapse with an initial shockable rhythm. Return of Spontaneous Circulation (ROSC) was achieved after 15 minutes of Advanced Cardiac Life Support (ACLS). Her post-resuscitation ECG shows diffuse ST-segment depression but no ST-segment elevation. She remains comatose.
Which of the following is the most appropriate next step in her management regarding coronary angiography?
A
Immediate emergency coronary angiography (within 2 hours) should be performed.
B
Routine emergency coronary angiography is not recommended in the absence of ST-segment elevation or hemodynamic instability.
C
Coronary angiography should be delayed for at least 72 hours to allow for neurological recovery.
D
Fibrinolytic therapy should be administered immediately if the patient cannot reach a cath lab within 90 minutes.
Explanation
The correct answer is B.In resuscitated patients who are comatose after cardiac arrest, electrically and hemodynamically stable, and without evidence of STEMI, immediate angiography is not recommended due to lack of benefit (Class 3: No Benefit; LOE A)Patients who have been resuscitated after cardiac arrest and are noncomatose or who are comatose with favorable prognostic features and with evidence of STEMI, should undergo PPCI to improve survival. (Class 1; LOE B-NR).For patients such as this one, a delayed or selective approach should be taken once the patient is stabilized. Early angiography should not be denied solely based on a comatose state, but it should be deferred if there are clear non-cardiac causes for the arrest or if the patient’s overall prognosis is futile.A is incorrect because recent evidence shows no benefit to “emergency” PPCI for stable patients without ST-elevation.C is incorrect because while we wait for stability, we don’t necessarily have a fixed 72-hour “mandatory” delay for the heart if ischemia is suspected.D is incorrect, as fibrinolysis is generally not indicated for post-arrest patients without clear STEMI and carries risks in a post-CPR setting due to potential trauma.The MIRACLE2 Score is a tool for neuroprognostication. It helps clinicians estimate the likelihood of a poor neurological outcome at 6 months. A high score suggests that the benefit of an invasive procedure may be outweighed by the severity of the brain injury.Components of MIRACLE2:M – Missed (unwitnessed) arrest
I – Initial non-shockable rhythm
R – Reactive pupils at ROSC
A – Age (points increase significantly at >60 and >80)
C – Rhythm change (e.g., VF to PEA)
L – Low pH (pH < 7.20)
E – Epinephrine (any dose given)Clinical Threshold: A score of >5 indicates a high risk of poor neurological recovery, which may lead a Heart Team to favor stabilization over immediate emergency angiography in patients without ST-elevation.Early recognition of STEMI in resuscitated patients and direct transfer to a PCI-capable center is associated with improved survival. Survival-to-hospital discharge in the patient who is comatose with out-of-hospital cardiac arrest is <10% regardless of etiology. Those with a witnessed arrest and a shockable rhythm have improved survival. Outcomes for patients with STEMI who are awake after resuscitated cardiac arrest are comparable to patients with STEMI who were not in cardiac arrest. For this reason, patients with cardiac arrest who have achieved return of spontaneous circulation (ROSC) and are awake with STEMI on ECG are candidates for PPCI. However, care should be individualized in the comatose patient with rapid assessment of the patient’s clinical features and cardiac arrest characteristics before proceeding with invasive angiography. In contrast, patients who are stable without ST-segment elevation after out-of-hospital cardiac arrest do not require immediate coronary angiography. Coronary angiography in this setting can be deferred pending further risk stratification.
Main Takeaway
Patients with cardiac arrest and STEMI who have been resuscitated should preferentially be transferred by EMS to a PPCI-capable center. Certain prognostic scores can help risk stratify patients prior to catheterization.
Guideline Loc.
Section 3.2. Management of Patients Presenting With Cardiac Arrest
...more
11min
August 21, 202611. AngioClub: TAVR in the Bicuspid Aortic Valve
In this AngioClub-style episode from the CardioNerds CathMasters, Drs. Amit Goyal, Nazli Okumus, Niko Spilias, and Grant Reed discuss transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) stenosis. Through a case of a 71-year-old man with severe aortic stenosis (AS), reduced left ventricular ejection fraction (LVEF), a recent heart failure hospitalization, and a heavily calcified Sievers type 1 BAV, the panel works through TAVR versus surgical aortic valve replacement (SAVR) selection, lifetime management, anatomic and procedural risk (paravalvular leak [PVL], permanent pacemaker [PPM], stroke, annular rupture), balloon/valve sizing, cerebral embolic protection (CEP), and expected LVEF recovery. The episode highlights that BAV is not itself a contraindication to TAVR but demands meticulous CT-based planning and phenotype-specific risk stratification.
CathMasters is for educational purposes only.
CathMasters is for educational purposes only. Music by Elijah K from Pixabay
Media
Pearls
BAV was excluded from the pivotal TAVR randomized trials — every comparison of TAVR vs SAVR in bicuspid anatomy comes from registries and observational cohorts, so shared decision-making and Heart Team review are essential.
“The more tricuspid-like the bicuspid valve behaves, the more predictable the TAVR.” Symmetric calcification and absence of a heavily calcified raphe/LVOT favor good outcomes.
The highest-risk BAV phenotype is a calcified raphe plus excess leaflet calcification — this combination tracks with roughly 3-fold higher 2-year mortality (~25.7%) and more aortic root injury and PVL; in general, avoid TAVR in these patients unless surgical risk is prohibitive.
“Perfection is the enemy of the good.” Accept mild PVL rather than aggressively post-dilating against a rock-hard calcified annulus, where chasing perfection risks annular rupture.
A high mean gradient despite a low LVEF signals afterload-mediated dysfunction with reserve — these ventricles often recover after TAVR; about one-third of low-EF patients show early LVEF improvement, and very-low-EF/low-flow cohorts recover even more.
Notes
When is TAVR reasonable instead of SAVR in a bicuspid valve?
SAVR remains first-line for truly young, low-risk BAV patients, particularly those <70–75 years, with aortopathy requiring repair, or with hostile annular/LVOT calcification.
BAV patients are increasingly encountered as TAVR expands to younger, lower-risk populations because bicuspid AS presents earlier — BAV represents ~50% of AS in younger patients and ~25% in those >80.
Registry and meta-analytic data show comparable short-term mortality but signals for higher stroke, PPM, PVL, and inferior long-term survival with TAVR vs SAVR in BAV; NOTION-2 showed a non-significant higher event rate with TAVR in the bicuspid subgroup (20.4% vs 7.8%).
The case patient’s low STS score (1.6%) underestimates true risk given severe mobility limitation, non-ischemic-appearing LV dysfunction, and a recent decompensated heart failure admission — factors not captured by STS-PROM that justified favoring TAVR after Heart Team discussion.
How does lifetime management inform the index procedure?
Lifetime management aims to minimize the number of sternotomies and to sequence interventions (redo-TAVR, valve-in-valve, TAVR explant/SAVR) optimally over a patient’s remaining lifespan.
Guidelines favor SAVR in patients <70 years with low surgical risk and TAVR as primary therapy in patients ≥70 years with tricuspid anatomy suitable for transfemoral access; all other candidates warrant individualized Heart Team decisions.
Key lifetime-management inputs include age/life expectancy, aortopathy, coronary access for future procedures, annular dimensions/patient–prosthesis mismatch, likelihood of PPM, and feasibility of future valve-in-valve.
What are the anatomic and procedural risks specific to bicuspid TAVR?
Principal risks: paravalvular leak (elliptical annulus, asymmetric sinuses, eccentric calcium), permanent pacemaker (especially right–left fusion pushing the frame toward the conduction system and with self-expanding valves), annular/root rupture, and stroke.
With new-generation devices, the historical gap in device success and PVL between BAV and tricuspid anatomy has narrowed substantially.
The highest-risk CT phenotype — calcified raphe plus excess leaflet calcification — is associated with higher aortic root injury (up to 4.5%), moderate/severe PVL (up to 6.5%), and ~25.7% 2-year mortality; this patient had excess leaflet calcification but a non-bulky raphe.
A prolonged baseline QRS (128 ms) plus right–left cusp fusion raises PPM concern; a high valve calcium score (>10,000 AU) plus internal carotid stenosis raises embolic concern.
How should the balloon and valve be sized in bicuspid anatomy?
Predilation goals are crossability and, more importantly, circular, well-expanded valve deployment within the limits of the calcium; adequate expansion of a properly sized valve is increasingly linked to reduced HALT, lower gradients, and durability.
For heavily calcified BAV, size the balloon conservatively — often to the minimum annular diameter and adjusted down further for focal annular calcium — with a low threshold to post-dilate for expansion (not to chase trivial PVL).
Balloon-expandable valves apply more radial force and expand calcified annuli more reliably; self-expanding platforms rely more on adequate predilation and are now sized/predilated to the average diameter per contemporary guidance.
Beyond the virtual basal ring, assess for root tapering and intercommissural distance a few millimeters above the annulus; downsize if the supra-annular root is restrictive to avoid root injury.
When should cerebral embolic protection be used?
The randomized PROTECTED TAVR trial found no statistically significant reduction in periprocedural stroke with CEP (2.3% vs 2.9%), though the confidence interval did not exclude benefit and disabling stroke was numerically lower (0.5% vs 1.3%).
Meta-analyses conflict: pooled randomized data (including PROTECTED TAVR and BHF PROTECT-TAVI) suggest no significant stroke reduction, whereas some analyses incorporating observational data report lower stroke.
Given the absence of a clear randomized benefit, use is individualized; a heavily calcified BAV with a very high calcium score, carotid disease, and planned predilation is a reasonable selective indication, though data does not strongly support this practice.
What LVEF recovery can be expected after TAVR in low-EF AS?
A high mean gradient (42 mm Hg here) despite LVEF 30–35% indicates predominantly afterload-mediated dysfunction with likely contractile reserve and favorable recovery potential.
Roughly one-third of high-/intermediate-risk patients with baseline LVEF <50% have early (≥10-point) LVEF improvement; low-flow/low-gradient patients with LVEF <30% show even larger absolute gains and outcomes independent of dobutamine contractile reserve.
Prior myocardial infarction, diabetes, coronary artery disease, and PPM are associated with reduced likelihood of LVEF recovery.
Case outcome mirrors this: LVEF rose to 40–45% by the next day and 55–60% at one month, with a mean gradient of 12 mm Hg, DVI 0.42, and only trace PVL.
References
Makkar RR, Yoon SH, Chakravarty T, et al. Association between transcatheter aortic valve replacement for bicuspid vs tricuspid aortic stenosis and mortality or stroke among patients at low surgical risk. JAMA. 2021;326(11):1034-1044. PubMed
Yoon SH, Kim WK, Dhoble A, et al. Bicuspid aortic valve morphology and outcomes after transcatheter aortic valve replacement. J Am Coll Cardiol. 2020;76(9):1018-1030. PubMed
Kapadia SR, Makkar R, Leon M, et al. Cerebral embolic protection during transcatheter aortic-valve replacement (PROTECTED TAVR). N Engl J Med. 2022;387(14):1253-1263. PubMed
Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2025. PubMed
Jørgensen TH, Savontaus M, Willemen Y, et al. Three-year follow-up of the NOTION-2 trial: TAVR versus SAVR to treat younger low-risk patients with tricuspid or bicuspid aortic stenosis. Circulation. 2025. PubMed
Nagasaka T, Patel V, Shechter A, et al. Impact of balloon-expandable TAVR valve deformation and calcium distribution on outcomes in bicuspid aortic valve. JACC Cardiovasc Interv. 2024;17(17):2026-2038. PubMed
Baman JR, Medhekar AN, Malaisrie SC, et al. Management challenges in patients younger than 65 years with severe aortic valve disease: a review. JAMA Cardiol. 2023;8(3):281-289. PubMed
Liu J, Wei D, Wu Q, et al. Comparison of short- and long-term outcomes between transcatheter and surgical aortic valve replacement for bicuspid aortic valve stenosis: a systematic review and meta-analysis. Int J Surg. 2025. PubMed
Mehaffey JH, Jagadeesan V, Kawsara M, et al. Transcatheter vs surgical aortic valve replacement in bicuspid aortic valves. Ann Thorac Surg. 2025. PubMed
Beerkens FJ, Tang GHL, Kini AS, et al. Transcatheter aortic valve replacement beyond severe aortic stenosis: JACC state-of-the-art review. J Am Coll Cardiol. 2025;85(9):944-964. PubMed
Gupta T, Malaisrie SC, Batchelor W, et al. Decision-making approach to the treatment of young and low-risk patients with aortic stenosis. JACC Cardiovasc Interv. 2024;17(21):2455-2471. PubMed
Praz F, Beyersdorf F, Haugaa K, Prendergast B. Valvular heart disease: from mechanisms to management. Lancet. 2024;403(10436):1576-1589. PubMed
Kolte D, Bhardwaj B, Lu M, et al. Association between early left ventricular ejection fraction improvement after transcatheter aortic valve replacement and 5-year clinical outcomes. JAMA Cardiol. 2022;7(9):934-944. PubMed
Maes F, Lerakis S, Barbosa Ribeiro H, et al. Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction less than 30%: a substudy from the TOPAS-TAVI registry. JAMA Cardiol. 2019;4(1):64-70. PubMed
Otto CM, Newby DE, Hillis GS. Calcific aortic stenosis: a review. JAMA. 2024;332(23):2014-2026. PubMed
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41min
August 02, 202610. Crisis Control: Bailout Management for Failed Percutaneous Axillary Artery Closure with Dr. Rajiv Tayal
CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss bailout management for failed percutaneous axillary artery closure with expert Dr. Raj Tayal. Building on the Data-to-Delivery and Proctor Playbook episodes, this Crisis Control episode walks through a scenario of wide-open extravasation after Perclose failure during right axillary access TAVR. The team covers a stepwise escalation algorithm — from repeat Perclose deployment and serial balloon tamponade with protamine reversal, to hybrid closure with AngioSeal, to covered stent placement with the Viabahn endoprosthesis — and discusses when to call vascular surgery. This episode translates the 2022 SCAI Position Statement bailout recommendations into a practical, cath-lab-ready crisis management framework.
CathMasters is for educational purposes only.
CathMasters is for educational purposes only. Music by Elijah K from Pixabay
Pearls
As long as wire access is maintained across the arteriotomy, the operator retains full bailout capability — the working wire going through the arteriotomy allows for repeat vascular closure device attempt, including Perclose and/or AngioSeal (hybrid closure), while the safety wire positioned in the axillary artery from the secondary access allows for balloon tamponade and/or covered stent deployment. Losing wire access is the true crisis.
If both Perclose sutures fail (snapped or cut), the “post-closure” rescue technique involves reinserting a large sheath, placing two 0.035″ wires side-by-side, removing the sheath, then inserting two 8F sheaths side-by-side for sequential Perclose deployment — maintaining wire access through the second sheath throughout.
A 6Fr sheath will accommodate 5-7 mm Viabahn covered stents while a 7Fr sheath will accommodate up to a 9mm Viabahn covered stent.
When deploying a covered stent from the radial artery without a destination sheath, use vascular markers on the screen to mark the bleeding site, lock the table position, and deploy based on those landmarks — retrograde contrast injection from the radial opacifies the vessel poorly compared to antegrade femoral injection.
Covered stent placement in the 2nd segment of the axillary artery has minimal long-term sequelae — there are no critical branches that, if covered, would cause significant ischemia. Covering the lateral thoracic artery is acceptable; the subscapular artery is less desirable but tolerable. Avoid occluding the suprascapular artery (1st segment).
Notes
1. Initial Assessment: Extravasation After Perclose Failure
Bleeding is the most common complication of transaxillary access. Risk increases with larger sheaths, patient age, longer dwell time, tortuosity, urgency, and anticoagulation status. Hemostasis failure can lead to bleeding into the axillary space with possible brachial plexus compression and permanent nerve injury. As the axillary artery is extrathoracic, hemothorax should not occur if vessel puncture was in the correct location.
The critical first question after failed closure: do you still have wire access through the arteriotomy and a safety wire in the artery? If yes, the full spectrum of bailout options remains available.
2. Stepwise Escalation Algorithm for Failed Closure
The following algorithm represents a synthesis of the SCAI Position Statement recommendations and Dr. Tayal’s practical approach:
Step 1 — Repeat Perclose: If one suture snapped but wire access is maintained, deploy an additional Perclose. This maintains wire access and allows interval assessment. If improvement is seen, proceed with observation.
Step 2 — Serial balloon tamponade: Advance the tamponade balloon to the arteriotomy site (not proximal to it), inflate at 4–6 atm with simultaneous external manual compression × 5 minutes → deflate → angiogram. Repeat for a second 5-minute cycle if needed.
Step 3 — Protamine reversal + balloon tamponade: Administer protamine, then repeat balloon tamponade × 5 minutes with external pressure. Thrombosis risk from protamine in an 8–10 mm axillary artery is low compared to coronary-sized vessels.
Step 4 — Hybrid closure (AngioSeal): If bleeding is minimal and appears to be tract oozing between sutures, deploy an AngioSeal collagen plug. Although this sacrifices wire access through the axillary arteriotomy, the 0.018″ safety wire from the secondary femoral/radial access provides continued bailout capability.
Step 5 — Covered stent: If bleeding persists after multiple tamponade cycles, proceed to covered stent deployment (see below).
Step 6 — Surgical repair: Reserved for scenarios where covered stent is not feasible or effective (see below).
3. Post-Closure Rescue Technique (Both Percloses Failed)
If both sutures are lost (snapped, cut, or pulled through), reinsert a large sheath (12–14F) to tamponade the arteriotomy.
Place two 0.035″ wires through the sheath.
Remove the sheath with both wires in place.
Insert two 8F sheaths side-by-side, one over each wire.
Deploy Perclose sequentially through one sheath while maintaining wire access through the other.
If post-closure Perclose also fails, pivot to AngioSeal or covered stent via the second sheath.
4. Covered Stent Selection and Deployment
Viabahn (W. L. Gore & Associates, Inc.) is the preferred covered stent for axillary artery bailout due to superior apposition and crush resistance in this mobile location. Self-expanding covered stents conform to the artery’s shape and adapt to the dynamic environment of the shoulder.
Sizing: oversize by ≥1 mm relative to the artery diameter. For most patients (average axillary artery 6–6.5 mm), a 7 or 8 mm Viabahn covers the majority of cases. A 9 mm is rarely needed.
Sheath compatibility: Viabahn 5–8 mm requires a 6–7F delivery system.
Delivery route:
Radial artery: A standard 6–7F slender sheath accommodates Viabahn up to 8 mm. However, visualization is limited (retrograde injection opacifies poorly). Use vascular markers on the screen to mark the bleeding site, lock the table, and deploy based on landmarks. The SCAI Position Statement recommends a long sheath from the radial approach, as passage of balloons and stents can induce spasm and entrapment.
Femoral artery: Preferred for the first 5–10 cases — allows antegrade contrast injection with superior visualization and accommodates larger sheaths/devices. A 7–8F long (90–110 cm) sheath is recommended.
Brachial artery: Avoid if possible; reserve for cases requiring stent sizes >8 mm when femoral access is unavailable.
Length: Use a 50 mm stent and err on the side of extra length. Attempting to be too precise with a short stent risks needing additional stents proximally or distally.
Post-dilation: Avoid if possible — post-dilating a self-expanding stent beyond its intended diameter causes foreshortening. Oversizing at initial deployment is preferable.
Branch vessel considerations: In the 2nd segment, covering the lateral thoracic artery is acceptable. The subscapular artery (3rd segment) is less desirable to cover. The suprascapular artery (1st segment) should not be occluded. The vertebral and internal mammary arteries (subclavian) must be avoided, but these are normally far proximal from the access site in the 2nd axillary artery segment.
Long-term outcomes: Covered stents in the axillary artery are well-tolerated with minimal long-term sequelae. The PAXA Registry reported secondary closure success in 98% of patients after adjunctive endovascular procedures (including 37 covered stents), with 100% axillary artery patency on follow-up CTA in the Al Adas et al. series.
5. When Covered Stent Is Not Feasible or Effective — Surgical Bailout
Covered stent may be infeasible when: (1) the delivery system cannot be advanced (severe tortuosity, spasm), (2) the injury is too proximal (1st segment near the thoracic outlet), or (3) a mechanical complication prevents device extraction (e.g., partially deployed balloon-expandable TAVR valve trapped in the artery as referenced in the podcast episode).
In the case described by Dr. Tayal, a balloon-expandable TAVR valve balloon ruptured on annular calcium, leaving a partially inflated valve that could not be fully deployed or withdrawn. The team pulled the device back into the axillary artery, inflated a proximal balloon to control bleeding, and a vascular surgeon performed a cutdown, extracted the device, placed a conduit, and the TAVR was completed successfully through the same artery.
Key principle: if the arteriotomy is in the 2nd segment, proximal vascular control can be achieved endovascularly (balloon tamponade), buying time for surgical involvement without catastrophic hemorrhage.
Direct surgical repair is preferable in some cases to avoid the risks of stent grafts (side branch occlusion, restenosis, thrombosis, infection, reduced mobility). In most cases, the arteriotomy can be repaired primarily unless there is significant atherosclerotic disease or vessel wall disruption, in which case patch angioplasty or interposition graft may be required.
6. Proactive Measures to Minimize Crisis
Notify vascular surgery before the procedure — share the plan, data, and bailout strategy. Collegial pre-procedural communication prevents adversarial dynamics if complications arise.
Have Viabahn stents (7 mm and 8 mm) in the room, not in a remote storage location.
Experienced operators should achieve a <2–3% failure rate requiring covered stent or surgical conversion. The PAXA Registry reported a 1.5% open conversion rate, and the Al Adas et al. series reported a 6.9% covered stent rate (trending down to 4% in the late cohort with experience).
Vascular complications from percutaneous transaxillary access, while reported at higher rates than transfemoral (up to 17% major vascular), do not appear to influence clinical outcomes when managed with proper endovascular techniques and materials.
References
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 ⭐ Key Reference
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 ⭐ Key Reference
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 ⭐ Key Reference
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 ⭐ Key Reference
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
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
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
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
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
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
Mach M, Okutucu S, Kerbel T, et al. Vascular complications in TAVR: incidence, clinical impact, and management. J Clin Med. 2021;10(21):5046. doi:10.3390/jcm10215046
Xenos ES, Freeman M, Stevens S, et al. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg. 2003;38(3):451-454. doi:10.1016/S0741-5214(03)00553-7
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
Bertoglio L, Mascia D, Cambiaghi T, et al. Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair. J Vasc Surg. 2018;68(1):34-40. doi:10.1016/j.jvs.2017.10.076
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
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
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
Sequeira A, Abreo K. The structure and function of endovascular stents: a primer for the interventional nephrologist. Semin Dial. 2014;27(3):272-282. doi:10.1111/sdi.12225
Chopra A, Modrall JG, Knowles M, et al. Uncertain patency of covered stents placed for traumatic axillosubclavian artery injury. J Am Coll Surg. 2016;223(1):34-41. doi:10.1016/j.jamcollsurg.2016.03.023
DuBose JJ, Rajani R, Gilani R, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785-1792. doi:10.1016/j.injury.2012.08.028
Feldman DN, Armstrong EJ, Aronow HD, et al. SCAI consensus guidelines for device selection in femoral-popliteal arterial interventions. Catheter Cardiovasc Interv. 2018;92(1):E165-E174. doi:10.1002/ccd.27635
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14min
July 10, 20269. Proctor Playbook: Percutaneous Transaxillary Access and Closure: State-of-the-Art Technique with Dr. Rajiv Tayal
CathMasters Drs. Amit Goyal, Li Pang, and Dr. Nazli Okumus, discuss state-of-the-art percutaneous axillary arterial access and closure with expert proctor Dr. Raj Tayal. 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.
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.
CathMasters is for educational purposes only.
CathMasters is for educational purposes only. Music by Elijah K from Pixabay
Pearls
Target the second segment of the axillary artery (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.
Arm abduction to 90° lengthens the second segment, brings the artery more superficially, and allows the operator to remain parallel to the vessel — reducing the tendency to splay the artery and cause occult bleeding beneath the pectoralis muscle.
The axillary artery has a thicker elastic lamina and a thinner muscular lamina than the femoral artery, 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.
Use an 0.018″ safety wire (not 0.014″) — 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.
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). Always have Viabahn stents in the room, not elsewhere!
Notes
1. Pre-Procedural Planning: CTA Checklist and Screening
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).
Per the SCAI Position Statement, absolute contraindications include a prior covered stent or surgical repair that renders the artery unsuitable for percutaneous access. Relative contraindications include vessel calcification, stenosis, tortuosity, aneurysmal dilatation, or prior dissection.
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.
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.
2. Laterality Selection: Left vs. Right
Left axillary access is generally preferred 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.
Right axillary access 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.
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.
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.
3. Room Setup and Arm Positioning
Arm abduction to 90° 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.
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.
For left-sided access, move monitors to the head of the bed or foot of the patient (similar to pacemaker implant setup). For right-sided access, standard room configuration can be maintained.
4. Equipment Checklist
Stiff micropuncture kit
Ultrasound with linear probe and sterile cover
Two Perclose devices (ProGlide or ProStyle)
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)
Pre-designated dry closure balloon: 8–10 × 40 mm compliant balloon (shorter balloons risk missing the arteriotomy)
Viabahn covered stents should be in the room — know the required sizes and sheath compatibility
6F and 8F sheaths, JR4 or 3DR diagnostic catheter, stiff exchange-length 0.035″ wire for sheath insertion.
5. Sedation
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.
Experienced operators (≥10 cases) can achieve large-bore sheath insertion and Impella deployment in 7–10 minutes, comparable to transfemoral access times.
6. Axillary Artery Anatomy — Target Zone
The axillary artery is divided into three segments relative to the pectoralis minor muscle:
1st segment (medial to pec minor): branch — superior thoracic artery
2nd segment (posterior to pec minor): branches — thoracoacromial artery, lateral thoracic artery
3rd segment (lateral to pec minor): branches — subscapular artery, anterior and posterior circumflex humeral arteries
The 2nd segment is the recommended target 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).
Angiographic landmarks for the access zone: 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.
The axillary artery typically measures 6–7 mm in diameter (range 5–8 mm).
7. Safety Wire Strategy
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.
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.
Wire entrapment risk: 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.
Critical: 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.
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.
8. Ultrasound-Guided Puncture Technique
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).
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.
Angle of approach: 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.
Stay within the deltopectoral groove — if the vessel is deeper than ~5 cm, the puncture is likely too low on the anterior chest wall.
Roadmap angiography is a useful backup tool but not routinely necessary for experienced operators.
9. Pre-Closure and Large-Bore Sheath Insertion
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.
Tissue dissection: 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.”
Perclose orientation in the axillary artery: place sutures at 11-and-1 o’clock or parallel at 12 o’clock 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.”
10. Closure Device Selection
Perclose (suture-mediated VCD) is the device recommended by the SCAI Position Statement — it permits rewiring and maintenance of access if the device fails.
Both ProGlide and ProStyle are acceptable. Collagen-plug devices (AngioSeal, Mynx, MANTA) do not allow preservation of access if they fail.
Hybrid closure (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.
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).
11. Dry Closure Choreography and Bailout Algorithm
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.
Step-by-step:
Inflate balloon to 2–4 atm → achieve endovascular hemostasis
Walk the large-bore sheath out over the 0.035″ wire
Pull and cinch the non-locking Perclose sutures
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)
Obtain a DSA in a slightly caudal angulation to evaluate the underside of the vessel
Bailout algorithm for persistent extravasation:
Advance balloon to the arteriotomy site → inflate 2–4 atm + external manual pressure × 5 minutes → deflate → angiogram
If still bleeding: repeat balloon tamponade × 5 minutes
If still bleeding: administer protamine → repeat balloon tamponade × 5 minutes
If still bleeding: proceed to covered stent (Viabahn preferred for superior apposition and crush resistance) or hybrid closure with AngioSeal
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.
Alternative Access for TAVR: A State-of-the-Art Review and Practical Guide. JACC Cardiovasc Interv. October 12, 2025.
Topography of the axillary artery.
Topography and Anatomical Variations of the Axillary Artery. Biomed Res Int. August 18, 2020.
References
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 ⭐ Key Reference
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 ⭐ Key Reference
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 ⭐ Key Reference
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
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
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
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
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
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. doi:10.1016/j.athoracsur.2020.06.105
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. doi:10.1016/j.jcin.2020.09.052
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. doi:10.1016/j.jcin.2022.08.040
Yang K, Lee H, Choi IJ, et al. Topography and anatomical variations of the axillary artery. Biomed Res Int. 2020;2020:4657876. doi:10.1155/2020/4657876
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. doi:10.1016/j.jvs.2017.12.062
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
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
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. doi:10.1016/j.echo.2024.12.004
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. doi:10.1002/14651858.CD013585.pub2
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
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
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
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
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. doi:10.1161/CIRCINTERVENTIONS.117.005456
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32min
July 06, 20268. Data to Delivery: Percutaneous Transaxillary Arterial Access and Closure with Dr. Rajiv Tayal
CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss the evidence base for percutaneous transaxillary large-bore arterial access and closure with expert faculty Dr. Rajiv Tayal. 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.
CathMasters is for educational purposes only.
CathMasters is for educational purposes only. Music by Elijah K from Pixabay
Pearls
The second segment of the axillary artery is the preferred access site 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).
“Bidirectional control is the fundamental principle of large-bore alternative access.” 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.
Stroke is the Achilles’ heel of transaxillary TAVR — 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.
More vascular complications ≠ more bleeding with percutaneous access. 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.
Axillary Impella enables early ambulation and device stability — 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.
Notes
1. Why Transaxillary Access Matters Now
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.
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.
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.
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.
2. Outcomes: Transaxillary vs. Transfemoral TAVR
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).
Procedural success rates for transaxillary TAVR are high (91–100% across observational studies).
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.
3. The Stroke Signal
Stroke rates with transaxillary TAVR are consistently elevated at 6–8% across multiple registries:
TVT Registry (Dahle et al.): 6.1% at 30 days with SAPIEN 3
CoreValve Extreme Risk Pivotal Trial: 7.5%
Hostile Registry (Palmerini et al.): 5.9% for transalternative access (92% transaxillary)
ACCESS Study: 8.0% overall (4.0% debilitating)
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.
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.
Laterality: 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.
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%).
4. Vascular Complications: Percutaneous vs. Surgical Cutdown
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.
Southmayd et al. systematic review (2020): Percutaneous large-bore axillary access had dramatically less major bleeding than surgical cutdown (2.7% vs. 18%).
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.
Dry closure 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.
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.
5. Other Complications: Brachial Plexus Injury, Pneumo/Hemothorax
Brachial plexus injury 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.
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.
Pneumo/hemothorax 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.
6. Transaxillary Mechanical Circulatory Support (MCS)
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.
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.
Dwell-time considerations: 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.
Device stability: 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.
Repositioning sheath: 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.
7. Learning Curve and Training
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.
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.
SCAI recommends learning percutaneous axillary access through proctorship for at least the first 2–3 procedures, with operators prepared for bailout strategies.
Training pathways include cadaveric courses for fellows transitioning to practice. No formal case-volume requirements have been established.
The technique is transferable from basic femoral access skills and requires facility with ultrasound-guided access, micropuncture technique, and dry closure principles.
8. Axillary Artery Anatomy: Key Points
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.
First segment (medial to pectoralis minor): Larger, more superficial, but proximity to the thoracic cavity increases pneumo/hemothorax risk. Difficult for surgical bailout.
Second segment (behind pectoralis minor): Preferred access site. Anterior surface is free of brachial plexus elements. Accessible for surgical repair. Compressible against the chest wall.
Third segment (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.
9. Is Transaxillary Access a Niche Skill or an Expanding Platform?
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.
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.
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.
References
⭐ 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. Link
⭐ 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. Link
⭐ 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. Link
⭐ 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. Link
⭐ 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. Link
⭐ 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. Link
⭐ 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. Link
⭐ 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. Link
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. Link
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. Link
⭐ 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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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. Link
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32min
July 03, 2026 7. ACS Guidelines Question #2 with Dr. Michelle O’Donoghue
This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.
The following question refers to Section 5.2.1 of the 2025 ACS Guidelines.
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.
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.
Question
Answer
QuestionAnswer
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 V2-V4. 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?
A
Proceed with primary PCI to LAD
B
Medical management with aspirin and enoxaparin
C
Medical management with aspirin and clopidogrel
D
Medical management with aspirin and ticagrelor
Explanation
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.
Main Takeaway
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.
Guideline Loc.
Section 5.2.1
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6min
June 29, 20266. AngioClub: A Multimodality Approach to Recalcitrant In-Stent Restenosis
CathMasters (Drs. Amit Goyal, Daniel Ambinder, Nazli Okumus, and Salman Allana) discuss a challenging case of recalcitrant focal in-stent restenosis (ISR) within two layers of stent in a right coronary artery. The panel walks through a systematic approach to ISR: guide selection and access strategy; the role of intracoronary imaging in classifying ISR using the Waksman mechanistic classification; and a stepwise lesion-modification algorithm using cutting balloons, excimer laser coronary atherectomy (ELCA), and intravascular lithotripsy (IVL). The discussion concludes with the contemporary role of drug-coated balloons (DCB) versus vascular brachytherapy (VBT), and when to consider rotational atherectomy (RA) for stent ablation in refractory cases.
CathMasters is for educational purposes only.
CathMasters is for educational purposes only. Music by Elijah K from Pixabay
Media
Coronary Angiography
OCT – First Run
OCT – Second Run
Final Angiography
Pearls
Always image before you intervene. Intravascular imaging (OCT or IVUS) is essential for classifying ISR using the Waksman mechanistic classification (Type I: mechanical; Type II: biologic; Type III: mixed; Type IV: CTO; Type V: multilayer) because the mechanism dictates the treatment strategy.
“Watermelon seeding” does not equal neointimal hyperplasia. While balloon slippage is classically associated with neointimal hyperplasia, it also occurs with calcified lesions that resist expansion. Do not assume the mechanism without imaging.
ELCA with contrast is not the same as ELCA with saline. Contrast infusion amplifies the photomechanical effect by generating cavitating microbubbles producing shockwaves equivalent to ~100 atm, enabling ablation of calcified neoatherosclerosis — but at the cost of increased risk of no-reflow and dissection. Use saline for predominantly biologic (NIH) lesions; consider adding contrast when calcium is present.
Recalcitrant ISR often requires multimodality lesion preparation. A single tool rarely suffices for Waksman Type III (mixed) ISR. In this case, cutting balloon addressed tissue disruption, ELCA ablated neointimal hyperplasia, and IVL cracked the calcified neoatherosclerosis — each targeting a different component of the disease.
Know your shelf and know your off-ramp. Not every lab has every tool. If adequate lesion modification cannot be achieved, have a plan to refer to a center with additional capabilities (e.g., brachytherapy, rotational atherectomy for stent ablation) rather than leaving a suboptimal result.
Notes
How should ISR be classified, and why does it matter?
The Waksman ISR Classification is an imaging-based mechanistic classification that guides treatment. It identifies 5 types: Type I — mechanical (IA: underexpansion; IB: stent fracture); Type II — biologic (IIA: neointimal hyperplasia; IIB: noncalcified neoatherosclerosis; IIC: calcified neoatherosclerosis); Type III — mixed mechanical and biologic; Type IV — chronic total occlusion; Type V — multilayer (>2 stent layers).
OCT is preferred over IVUS for characterizing the neointimal tissue (NIH vs. neoatherosclerosis vs. calcium), though IVUS provides complementary information on stent expansion and persistent calcium.
In this case, OCT revealed Waksman Type III ISR: a combination of neointimal hyperplasia and calcified neoatherosclerosis within two layers of stent that were reasonably well expanded — meaning both biologic and mechanical components required treatment.
What is the stepwise approach to lesion modification in recalcitrant ISR?
Steps will vary based on lesion characteristics, operator experience, and availability of cath lab devices. The following is specific to the case discussed in this podcast.
Step 1 — Noncompliant (NC) balloon: Start with a small NC balloon (2.0–2.5 mm) to predilate and create a path for imaging catheters. This also provides initial diagnostic information about lesion compliance.
Step 2 — Cutting/scoring balloon: If the NC balloon watermelon seeds or fails to expand, use a cutting balloon (e.g., Wolverine) or scoring balloon (e.g., AngioSculpt, ScoreFlex) to anchor and disrupt tissue. Sizing strategies vary by operator:
One-to-one sizing at nominal to moderate pressures (12–14 atm)
Undersizing by 0.5 mm and going to higher pressures (up to 18–20 atm) with slow inflation/deflation
Step 3 — Atheroablative therapy (ELCA or RA): If persistent waist remains after cutting balloon + NC:
ELCA is preferred for predominantly biologic (NIH) ISR. For the 1.4 mm catheter, max settings are 60 mJ/mm² fluence and 40 Hz repetition rate. Advance slowly at 0.5–1 mm/sec. Use saline flush for NIH; 50/50 contrast/saline for calcified neoatherosclerosis.
RA is preferred for calcified neoatherosclerosis or underexpanded stents. Start with a 1.5-mm burr at 160,000–180,000 RPM for calcific disease (treat as de novo). For underexpanded stents, longer runs at 200,000–220,000 RPM may be needed — advance very slowly to avoid burr entrapment.
Step 4 — Intravascular lithotripsy (IVL): Size 1:1 to the reference vessel. IVL is particularly effective for calcium behind stent struts, causing underexpansion. A meta-analysis of 354 patients showed an 88.7% strategy success rate for IVL in stent underexpansion. IVL may be less effective for calcified neoatherosclerosis (calcium within the stent lumen) compared to peri-stent calcium.
Step 5 — High-pressure NC or OPN balloon: After calcium modification, follow with aggressive NC balloon postdilation. OPN (ultra-high-pressure) balloons are an option, but are bulky and may be difficult to deliver.
What is the role of ELCA in ISR, and how does contrast flush change the game?
ELCA produces monochromatic UV light (308 nm wavelength) that ablates tissue via three mechanisms: photochemical (direct molecular bond disruption), photothermal (heat generation), and photomechanical (acoustic shockwave from vapor bubble formation).
Contrast flush amplifies the photomechanical effect by generating cavitating microbubbles that produce shockwaves equivalent to ~100 atm, enabling disruption of calcified tissue that saline-only ELCA cannot address.
Available catheter sizes: 0.9, 1.4, 1.7, and 2.0 mm. For ISR, 1.4 mm is typically the starting size. The 0.9 mm catheter is reserved for very tight or balloon-uncrossable lesions. Catheter size should not exceed two-thirds of the vessel diameter.
The ROLLER COASTR trial (171 patients) randomized patients with calcified coronary stenosis to RA, IVL, or ELCA. IVL was noninferior to RA for stent expansion, but ELCA narrowly failed to meet the noninferiority margin versus RA in the intention-to-treat analysis — suggesting that for heavily calcified de novo lesions, RA and IVL may be superior to ELCA.
However, for ISR specifically, ELCA combined with DCB may offer advantages. The ELDISR trial (110 patients) randomized patients with ISR to ELCA + balloon angioplasty vs. balloon angioplasty alone and showed benefits with ELCA. Smaller studies have shown ELCA + DCB yields lower TLR than DCB alone (~10% vs. 20% at 1 year).
DCB vs. brachytherapy — what is the contemporary approach to antiproliferative therapy in ISR?
Drug-coated balloons (DCB): The AGENT IDE trial randomized ~600 patients with coronary ISR to paclitaxel-coated balloon (Agent DCB) vs. uncoated balloon. DCB significantly reduced 12-month target lesion failure (TLF), driven by lower ischemia-driven TLR and target-vessel MI. Notably, zero cases of stent thrombosis occurred in the DCB arm vs. 6 cases (3.2%) in the control arm. Approximately 60% of enrolled patients had single-layer ISR, so the applicability to multilayer ISR was initially uncertain. A subsequent subgroup analysis showed consistent DCB benefit in both single-layer and multilayer ISR, with particularly striking absolute risk reduction in the multilayer cohort (TLF ~24% vs. ~40%).
Vascular brachytherapy (VBT): Remains a viable option, particularly for recurrent ISR after DCB failure. TLR rates with brachytherapy are approximately 29–30% at 2 years in single-center series. Logistical challenges include the need for a radiation source, radiation oncologist, and radiation physicist in the lab, making it an elective/scheduled procedure.
Contemporary practice: DCB is increasingly used as first-line antiproliferative therapy for ISR, given ease of use and strong trial data. VBT is reserved as a backup for recurrent ISR after DCB failure. No high-quality randomized data directly compare DCB to VBT. The longest available DCB is 30 mm, so diffuse ISR lesions exceeding this length may favor VBT.
ELCA + DCB combination: Emerging data suggest that combining ELCA with DCB may be superior to DCB alone, particularly for debulking neointimal tissue before drug delivery. This combination is supported by the ELDISR trial and smaller observational studies.
When and how to use rotational atherectomy for ISR and stent ablation
RA ablates both neointimal tissue and metallic stent struts via differential cutting (preferentially ablating hard, inelastic material).
For calcified neoatherosclerosis: treat similarly to de novo calcified disease. Start with a 1.5 mm burr at 160,000–180,000 RPM.
For underexpanded/dog-boning stents refractory to other modalities, prolonged RA runs at 200,000–220,000 RPM may be required. Advance very slowly to minimize the risk of burr entrapment. May need to upsize to 1.75 or 2.0 mm burr.
The ROSTER trial (200 patients, BMS-ISR) showed RA reduced TLR vs. balloon angioplasty at 12 months (32% vs. 45%). The ARTIST trial (298 patients) showed no benefit — likely because stent underexpansion was not excluded by IVUS, and RA is less effective for radial expansion of an underexpanded stent without calcium.
After RA for stent ablation, consider DCB rather than adding a third stent layer. The threshold for implanting a third stent layer should be very high.
Practical tips for guide selection and access in complex ISR
Femoral access is preferred for complex RCA ISR in post-CABG patients to maximize guide support.
A 7-French system is recommended to accommodate larger devices (ELCA, IVL, RA).
AL 1.0 or AL 0.75 guides provide excellent support for the RCA.
Longer sheaths (e.g., 45 cm) provide additional backup support.
A GuideLiner may be needed for device delivery in long, fully stented segments.
Wire choice is critical: use a supportive wire for device delivery, but be cautious about distal wire perforation in small, diseased branches.
References
★ Klein LW, Nathan S, Maehara A, et al. SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis. J Soc Cardiovasc Angiogr Interv. 2023;2(5):101048. https://doi.org/10.1016/j.jscai.2023.101048
★ Giustino G, Colombo A, Camaj A, et al. Coronary In-Stent Restenosis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022;80(4):348-372. https://doi.org/10.1016/j.jacc.2022.05.017
★ Yeh RW, Shlofmitz R, Moses J, et al. Paclitaxel-Coated Balloon vs Uncoated Balloon for Coronary In-Stent Restenosis: The AGENT IDE Randomized Clinical Trial. JAMA. 2024;331(13):1098-1107. https://doi.org/10.1001/jama.2024.3107
★ Kirtane AJ, Shlofmitz R, Moses J, et al. Paclitaxel-Coated Balloon for the Treatment of Multilayer In-Stent Restenosis: AGENT IDE Subgroup Analysis. J Am Coll Cardiol. 2025;86(7). https://doi.org/10.1016/j.jacc.2025.05.xxx
★ Ng P, Maehara A, Kirtane AJ, et al. Management of Coronary Stent Underexpansion. J Am Coll Cardiol. 2025;85(7):713-731. https://doi.org/10.1016/j.jacc.2024.12.003
★ Riley RF, Patel MP, Abbott JD, et al. SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions. J Soc Cardiovasc Angiogr Interv. 2024;3(2):101259. https://doi.org/10.1016/j.jscai.2023.101259
Jurado-Román A, Gómez-Menchero A, Rivero-Santana B, et al. Rotational Atherectomy, Lithotripsy, or Laser for Calcified Coronary Stenosis: The ROLLER COASTR-EPIC22 Trial. JACC Cardiovasc Interv. 2025;18(5):573-584. https://doi.org/10.1016/j.jcin.2024.12.025
He P, Chen H, Yang J, et al. Debulking With Excimer Laser Coronary Angioplasty Versus Balloon Angioplasty in Patients With In-Stent Restenosis (ELDISR Study): A Randomized Controlled Trial. Lasers Surg Med. 2025;57(4):e70007. https://doi.org/10.1002/lsm.70007
He P, Chen H, Yang J, et al. Excimer Laser Coronary Angioplasty Combined With Drug-Coated Balloon in the Treatment of In-Stent Restenosis. Lasers Surg Med. 2024;56(6):567-576. https://doi.org/10.1002/lsm.23797
Maqsood MH, Zhang RS, Rawal N, et al. Drug-Eluting Stent, Drug-Coated Balloon, or Plain Old Balloon Angioplasty for In-Stent Coronary Restenosis: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials. Circ Cardiovasc Interv. 2025;18(11):e014671. https://doi.org/10.1161/CIRCINTERVENTIONS.124.014671
Siontis GC, Stefanini GG, Mavridis D, et al. Percutaneous Coronary Interventional Strategies for Treatment of In-Stent Restenosis: A Network Meta-Analysis. Lancet. 2015;386(9994):655-664. https://doi.org/10.1016/S0140-6736(15)60657-2
Caminiti R, Vetta G, Parlavecchio A, et al. A Systematic Review and Meta-Analysis Including 354 Patients From 13 Studies of Intravascular Lithotripsy for the Treatment of Underexpanded Coronary Stents. Am J Cardiol. 2023;205:291-298. https://doi.org/10.1016/j.amjcard.2023.07.148
Farhat H, Kuzemczak M, Durel N, et al. Rotational Atherectomy Versus Intravascular Lithotripsy for Calcified In-Stent Restenosis: A Single-Center Study With 1-Year Follow-Up. Am J Cardiol. 2023;205:83-89. https://doi.org/10.1016/j.amjcard.2023.07.155
Sharma SK, Kini A, Mehran R, et al. Randomized Trial of Rotational Atherectomy Versus Balloon Angioplasty for Diffuse In-Stent Restenosis (ROSTER). Am Heart J. 2004;147(1):16-22. https://doi.org/10.1016/j.ahj.2003.07.013
Alfonso F, Byrne RA, Rivero F, Kastrati A. Current Treatment of In-Stent Restenosis. J Am Coll Cardiol. 2014;63(24):2659-2673. https://doi.org/10.1016/j.jacc.2014.02.545
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. J Am Coll Cardiol. 2022;79(2):e21-e129. https://doi.org/10.1016/j.jacc.2021.09.006
Tomey MI, Kini AS, Sharma SK. Current Status of Rotational Atherectomy. JACC Cardiovasc Interv. 2014;7(4):345-353. https://doi.org/10.1016/j.jcin.2013.12.196
Yasumura K, Koshy AN, Vengrenyuk Y, et al. Predictors of Suboptimal Lumen Expansion Following Intravascular Lithotripsy for Coronary In-Stent Restenosis. JACC Cardiovasc Interv. 2024;17(2):225-237. https://doi.org/10.1016/j.jcin.2023.10.048
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42min
June 25, 2026 5. ACS Guidelines Question #1 with Dr. Sunil Rao
The following question refers to Section 7.1 of the 2025 ACS Guidelines.
The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by University of Michigan fellow and CardioNerds FIT Ambassador Dr. Kayla Secrest, and then by expert faculty Dr. Sunil Rao.
Dr. Rao is an interventional cardiologist, Professor of Medicine at NYU Grossman School of Medicine, Deputy Director of the Leon H. Charney Division of Cardiology, and the Director of Interventional Cardiology for the NYU Langone Health System. He is the Editor-in-Chief for Circulation Cardiovascular Interventions and was the Chair of the Writing Committee for the 2025 ACS Guidelines.
This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.
Question #1
A 68-year-old man with a history of hypertension, hyperlipidemia, stage III chronic kidney disease, and prior tobacco use presents to a local emergency department with reports of chest pain while raking leaves at home. Upon arrival, he is hemodynamically stable with a heart rate of 86 beats per minute and a blood pressure of 133/85 mmHg. His EKG reveals ST elevations in the septal and anterior leads (V1-V4). He is given 324mg of aspirin and is promptly evaluated by the interventional cardiology team, who elects to take him emergently to the catheterization lab. Upon arrival to the catheterization lab, the nurse asks the interventional fellow which access sites they should prep for this case? How should the interventional fellow respond?
A
Right radial artery only
B
Radial + bilateral femoral
C
Bilateral femoral only
Click to Reveal Answer
Explanation
The correct answer is B. Radial and bilateral femoralRadial artery access is the preferred vascular access site for coronary angiography and PCI in patients with ACS. Transradial access has been shown to reduce mortality, bleeding, and vascular complications compared with transfemoral access (Class I, LOE A). Radial access also allows earlier ambulation and is associated with greater patient comfort.Although the right radial artery is the most widely studied upper-extremity access site, alternative sites such as the ulnar and distal radial arteries have demonstrated similar outcomes.However, the radial artery may be required as a bypass conduit for CABG. In institutions where the radial artery is routinely used for surgical grafting, this potential future use should be considered when selecting vascular access.In addition, transfemoral access—preferably performed with ultrasound guidance—should be considered in patients in whom temporary mechanical circulatory support (MCS) is anticipated or in those for whom radial access is not feasible due to anatomical or technical constraints. Prepping bilateral groins in addition to the radial artery provides a backup strategy for urgent MCS placement or for transition to femoral access should radial access fail.For these reasons, prepping both the radial artery and bilateral groins is the most appropriate response.Radial-only preparation is incorrect because, although radial access is preferred, patients with STEMI may still require emergent MCS or alternative access if the radial artery is unsuitable. Preparing only the wrist without backup femoral access may delay care should hemodynamic instability occur.Femoral-only preparation is incorrect because transradial access provides superior outcomes in ACS, including significant reductions in all-cause mortality, major bleeding, and vascular complications. RCTs and meta-analyses, including MATRIX (which showed lower MACE and net adverse clinical events with radial access) and SAFARI-STEMI (which showed no difference in mortality but was underpowered)—support radial as first-line access when feasible.
Main Takeaway
For patients with ACS undergoing PCI, radial access is strongly preferred to reduce mortality, bleeding, and vascular complications.
Guideline Loc.
Section 7.1
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10min

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