**6.1 Introduction**

*Vascular Access Surgery - Tips and Tricks*

sites and for an antero lateral thoracotomy

to tear through the ventricular tissue.

transfemoral approach

across the aortic valve

the aortic annulus [11]

sheath

• Femoral artery and vein access is achieved as routinely

catheter is placed in aortic root via femoral artery

left chest

• Supine position with both arms tucked at the sides and a small roll under the

• It is important to prep patient widely to include all potential CPB cannulation

• A femoral transvenous pacing lead is inserted in right ventricle and a pigtail

• In cases of a previous sternotomy, adhesions are released between the pericar-

• Two apical concentric pledgeted 3–0 PROLENE purse-string sutures are placed

• The purse-string sutures must be deep into the myocardium as they are prone

• The Left ventricle is punctured with a needle and a 0.035″ J wire is passed into

• Fluoroscopy is used to align all three aortic cusps in the same plane asin

• The 0.035″ guide wire is then exchanged for an Amplatz super-stiff wire

• The 7-French sheath is exchanged for the appropriate transapical delivery

• If there is bleeding around the sheath, the purse-string sutures can be snared

• The valve is aligned parallel to the long axis of the aorta and perpendicular to

• Both transesophageal echocardiography (TEE) and aortic root angiogram

under fluoroscopy are used to confirm the position of the valve

• The bioprosthetic valve is delivered through the sheath and positioned

• Anterolateral thoracotomy is made in the fifth or sixth intercostal space

• Dissection is carried down to the pleura and a rib retractor is placed

• After identifying the phrenic nerve, the pericardium is opened

dium and epicardium for adequate exposure of the LV apex

• The patient is heparinized to maintain an ACT 200–250 s

the LV, across the aortic valve and into the ascending aorta

• The needle is exchanged for a 7-French sheath

just cephalad to the apex and lateral to the LAD coronary artery

**12**

The transaortic approach was originally reported by Bapat et al. [12, 13]. The concept behind this first report was the use of the short transapical TAVI delivery system for the retrograde TAVI implant through the ascending aorta. Since then it has become a valid option in case of severe peripheral vascular disease [14].
