**4.1 Introduction**

*Vascular Access Surgery - Tips and Tricks*

fluoroscopic guidance

and positioning.

ing thoracic aorta (DTA).

• Patient lies supine on operating table

• Endotracheal intubation, arterial line and central line with temporary pace

• Femoral arteries are accessed percutaneously under vascular ultrasound or

• Surgical cut down can be considered in obese patients with deep femoral arteries

• These days routinely we are using right radial artery for placing Pigtail catheter

• IV heparin is given to keep activated clotting time (ACT) around 200–250 s.

• Another femoral artery is used to insert 18 Fr valve deployment sheath. First a 6 Fr sheath is inserted and then a soft, J-tipped wire is placed into the descend-

• Two percutaneous sutures based vascular closure devices (Per close devices) are placed, which are used to control the bleeding after the procedure.

• The soft J-tipped wire and an exchange catheter are inserted into the aorta

• 18 Fr sheath is inserted after making a small nick with 11 blade at the puncture

• Contra lateral pigtail catheter should be pulled out a little before the opening the valve fully; to prevent the entrapment of the pigtail catheter in device

• Rapid ventricular pacing is done to decrease the blood pressure and valve is deployed under fluoroscopic and transesophageal echocardiographic guidance

• At completion of the procedure we reverse the ACT by giving protamine and then remove the deployment sheath first and control bleeding by per close devices.

• In case of doubtful control of bleeding or suspicion of femoral artery stenosis, we do check angiography using cross over from the contralateral femoral artery

• 6Fr sheath is inserted in one femoral artery and then a 5 Fr pigtail catheter is placed in non-coronary sinus of aorta as a marker for aortic valve placement

maker lead through right internal jugular vein and placed

in non-coronary sinus of aorta instead of femoral artery

• A soft wire is exchanged for a super-stiff Amplatz wire

• Then catheter and 6-Fr sheath are removed

site in order to facilitate entry of bigger sheath

• Valve deployment is done through the 18-Fr sheath

• We usually extubate the patient in operating room

• Surgical part painted and draped from neck down till mid-thigh

**3.3 Technique**

**8**

The subclavian artery has recently become a site of access for TAVI [7]. Right axillary or subclavian artery is rarely used for TAVI because of anatomic restrictions and unfavourable angle for valve implantation. The proximal third of the left axillary artery (between the lateral border of the first rib and the medial border of the pectoralis minor) represents the ideal target for both surgical and percutaneous approaches.

A study suggested that subclavian access is not advisable in patients with subclavian artery diameter <7 mm, significant tortuosity, or prior coronary artery bypass grafting (CABG) and patent in situ internal mammary artery grafts [8].
