**8.1 Introduction**

*Vascular Access Surgery - Tips and Tricks*

This approach is used rarely and required in only for the patients who have contraindications to all other accesses. Modine reported a successful series of 12 patients who underwent CoreValve TAVI with no access site complications, no

Mylotte et al. [17] reported the feasibility and the safety of this transcarotid approach in 96 patients enrolled in 3 different French sites. In their series, no major bleedings nor vascular complications related to the access site occurred, while only

• Common carotid artery diameter must be >8 mm without any calcification,

• CT angio carotid and brain to rule out significant atherosclerotic disease and to

• A 6-F sheath is placed in the femoral artery and an angled pigtail catheter is

• The right common carotid artery is exposed by vertical lower neck incision

• After proximal cross-clamping of the common carotid artery, it is opened

• The de-aired bypass shunt is placed through the arteriotomy into the distal

• Cerebral oximetry is monitored for both the cerebral hemispheres during the

• Through the proximal portion of the arteriotomy, a 0.035-inch J-tipped wire

• A multipurpose catheter is then inserted and a straight wire is used to cross the

• Under TEE and fluoroscopic guidance bioprosthetic valve is deployed as in

• After the procedure the wires, catheters, and sheath are removed, and the

stroke, and only 1 TIA contralateral to the accessed side [16].

three transient ischemic attacks and no strokes were reported.

assess patency of the circle of Willis and cerebral circulation

• MRI brain is done assess the patency of circle of Willis.

• A transvenous pacing lead is placed via the femoral vein

and 7-F introducer are placed in the ascending aorta

carotid artery is repaired with a pericardial patch.

• The straight wire is exchanged for an Amplatz extra-stiff wire

utilized for ascending aortography

carotid to maintain cerebral perfusion

longitudinally for 2.5 cm

whole procedure

aortic valve

other approaches

**7. Transcarotid approach**

stenosis or tortuosity

**7.1 Introduction**

**7.2 Planning**

**7.3 Technique**

**16**

The transcaval approach, described by Greenbaum et al. [18] is considered as the last resort in patients not qualifying for any other vascular access. In the transcaval approach (**Figure 7**), the delivery system is inserted through the femoral vein and crossed to the arterial system by creating an aortocaval fistula, which is closed with an Amplatzer device after the valve is deployed.

A case series demonstrated the feasibility of the transcaval TAVI, revealing a successful valve deployment in 17 of 19 patients despite a 79% rate of transfusion and a 33% rate of vascular complications [18].
