Name: Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation (Video) | JoVE Journal
Uploaded: 2025-08-08T13:10:00.000+00:00
Duration: 6 min 4 s
Description: Learn an upper-extremity approach for secondary access in transfemoral TAVI using ultrasound-guided venous puncture and temporary pacing lead insertion. This technique reduces bleeding complications and enables faster patient mobilization.

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5 minutes

This work was supported by a research grant (A 1678426/SVZ) from Medtronic.

The following method has been investigated in a previous trial (TAVI XS)17. Written informed consent was obtained from all participants prior to study enrollment. The trial was conducted in accordance with the principles of ICH-GCP, applicable privacy requirements, and guiding principles of the Declaration of Helsinki. The TAVI XS trial has been approved by the Medical Research Ethics Committee Oost-Nederland and the review board of each participating site.
1. Patient inclusion and exclusion
<ol>
	<li>All patients aged 18 years or older undergoing transfemoral TAVI should be considered for this method, provided no exclusion criteria are present.</li>
	<li>Exclude patients with a contraindication for upper-arm venous access&#160;(e.g.,&#160;known disruption of vascular patency after extensive thoracic surgery). Exclude patients if any contraindications for radial arterial access are present (e.g., known arterial occlusion after prior angiography or occlusion of the arteries due to peripheral artery disease). Exclude patients if a cerebral embolic protection device (requiring an additional arterial access) will be used.</li>
	<li>Treat patients who already have a permanent pacemaker implanted using a pacing-over-the-wire strategy, and consider them ineligible for the method presented in Step 2. 
	NOTE: The methods presented below can be performed using only local anesthetics. The use of general anesthesia or conscious sedation depends on patient characteristics and is neither a contraindication nor a requirement for performing the presented methods. Materials used in the methods described below are listed in the Table of Materials. The methods below describe the upper arm venous access and radial arterial access separately, as both approaches can be employed independently based on patient characteristics and procedural requirements.</li>
</ol>
2. Upper-extremity temporary pacing lead placement
<ol>
	<li>Patient positioning
	<ol>
		<li>Instruct the patient to get into a supine position on the catheterization table. Make sure the arm (preferably left) is fully extended at a 90&#176; angle relative to the thorax while remaining in the same vertical plane (Figure 1). 
		NOTE: The materials required are shown in Figure 2.</li>
		<li>Support the extended arm of the patient by making use of an armrest. Let the patient overextend and supinate their arm, by doing so presenting the medio-ventral side of the upper arm towards the operator.</li>
	</ol>
	</li>
	<li>Access site preparation
	<ol>
		<li>Make sure the access site is disinfected with either chlorhexidine or povidone-iodine by disinfecting the whole upper arm. This is important as prior to ultrasound, the exact location of the puncture is unknown.</li>
		<li>Place a tourniquet around the upper arm as proximally as possible and tighten it to enhance the visibility of the upper arm veins (basilic, cephalic, and brachial vein).</li>
		<li>Create a sterile field by placing a sterile cover that only reveals the disinfected upper arm.</li>
		<li>Prepare ultrasound-guided puncture using a vascular probe, sterile probe cover, and ultrasound gel.</li>
	</ol>
	</li>
	<li>Access site puncture
	<ol>
		<li>Use ultrasound to localize a suitable vein for puncture, a suitable vein is usually located 5-10 cm proximally to the elbow crease. In most cases this will either be the basilic vein (medio-ventral) or the cephalic vein (lateral). In some cases, the brachial vein is the most optimal for puncture.</li>
		<li>Determine the suitability of the vein based on the factors described below.
		<ol>
			<li>Select based on proximity to related structures prone to result in complications when punctured. For example, in some cases, a suitable vein is located very close to one of the arteries. In this case, try following the vein more proximal or distal to find an alternative location.</li>
			<li>Select based on the depth of the vein; a superficially located vein is preferable.</li>
			<li>Select based on the diameter of the vein, i.e., larger veins are more suitable for puncture.</li>
			<li>Select based on location of the puncture site, puncturing close to the elbow crease potentially causes pacemaker malfunction when the RV pacing lead is kept in place after the procedure. Make sure flexing of the arm is possible without compromising the pacing lead.</li>
		</ol>
		</li>
		<li>Once a suitable vein is chosen, confirm that it is a vein by compressing it with the echo probe before puncturing. A vein should collapse, whereas an artery will not.</li>
		<li>Infiltrate the subcutaneous space of the desired access site with 1-2 mL of 1% lidocaine solution (Figure 3A).</li>
		<li>Puncture the vein with a hollow needle, which is usually present in the 6 Fr sheath kit, using direct ultrasound guidance and make sure that sufficient backflow is present (Figure 3B,C).</li>
		<li>Directly afterward, insert a guidewire in the hollow needle and advance the guidewire (Figure 3D). After doing so, remove the tourniquet and remove the hollow needle back over the wire.</li>
		<li>Flush the sheath and side port before introducing it to make sure there is no air within the system.</li>
		<li>Introduce the 6 Fr sheath over the wire and then remove the guidewire and dilator. After this step, a 6 Fr lumen is created through which a temporary pacing lead can be inserted with additional room for the side port to inject intravenous fluids when required (Figure 3E).</li>
		<li>Introduce a 5 Fr flow-directed pacing catheter through the sheath with the balloon deflated. Advance the pacing lead following step 2.4.</li>
	</ol>
	</li>
	<li>Imaging guidance set-up and lead advancement
	<ol>
		<li>Use fluoroscopy when advancing the pacing lead towards the right ventricle. Use an anterior-posterior (0&#176;/0&#176;) view.</li>
		<li>Advance the pacing lead; the lead should naturally follow the vasculature toward the right ventricle without any resistance.</li>
		<li>Once the tip of the lead is situated within the subclavian vein, inflate the balloon tip to assist in directing the catheter tip towards the right ventricle. 
		NOTE: Once the tip of the catheter is situated medial to the head of the humerus (which can be confirmed using fluoroscopy), the tip is likely situated in the subclavian vein. If there is any resistance during the advancement of the lead, a contrast injection can be used to confirm that the tip of the catheter is situated in a vessel with a large enough diameter to inflate the balloon (the vessel diameter should be at least twice the diameter of the deflated catheter tip).</li>
		<li>If the pacing lead instead enters either the contralateral subclavian vein (which can be identified by the pacing lead advancing to the contralateral side surpassing the median line) or the jugular vein (which can be identified by the pacing lead advancing cranially after passing the midclavicular line), partially retrieve the lead and try to rotate the pre-shaped angulated tip of the pacing lead before advancing again. 
		NOTE: Contrast injections through the side port of the 6 Fr sheath can be used to facilitate proper passage of the lead and to confirm the pacing wire is advancing towards the right ventricle.</li>
		<li>Pass the tricuspid valve by slightly rotating the pacing lead towards the right ventricle and pass the tricuspid valve with an inflated balloon tip.</li>
		<li>In the right ventricle, make contact with the right ventricular apex and deflate the balloon afterward.</li>
	</ol>
	</li>
	<li>Connecting and testing the pacing lead
	<ol>
		<li>When the pacing lead is in the right position, connect the electrode plugs to the corresponding ports on the adapter.</li>
		<li>Perform a capture threshold test of the temporary pacing lead by pacing 20 beats per minute above the intrinsic heart rate at maximum pacemaker output and slowly decrease output amperage until malcapture (defined as pacing stimuli not resulting in depolarization, which can be identified by the presence of an irregular heartbeat and a heart rate that is lower than expected based on the pacemaker settings). The chosen pacemaker setting should exceed at least 2x this threshold value.</li>
		<li>When a threshold of &#62; 3 mA is found, reposition the pacing lead to achieve lower thresholds.</li>
	</ol>
	</li>
	<li>Fixating the pacing lead
	<ol>
		<li>Fixate the temporary pacing lead by using a large transparent film dressing covering the access site and about 10 cm of the remaining extrabodily located part of the pacing lead (Figure 4). Position this part of the pacing lead in a rolled-up fashion to prevent pacing lead dislocation due to movement of the upper arm or pacemaker device.</li>
		<li>Make sure the pacing lead is properly fixated in case patients require extended pacing or backup of the temporary lead (this allows mobilization with the pacing lead in situ).</li>
	</ol>
	</li>
	<li>Access closure (in case of lead removal after the procedure)
	<ol>
		<li>If removal of the pacing lead is warranted, reassure the balloon is deflated and retrieve the pacing lead with slight traction.</li>
		<li>Make sure the 6 Fr. Sheath remains in situ until activated clotting time (ACT) is normalized. Thereafter, remove the sheath manually.</li>
		<li>Use manual compression of the access site for 2 min. Place a sterile bordered gauze or island dressing afterwards for access site closure. If deemed necessary, use a bandage with slight compression instead.</li>
	</ol>
	</li>
</ol>
3. Upper-extremity secondary arterial access
NOTE: Step 3 can be performed independently from step 2 (e.g. when a pacing-over-the-wire strategy is used). In case both steps are performed, step 3 can be performed directly after 2.6.2.
<ol>
	<li>Patient positioning
	<ol>
		<li>Instruct the patient to get into a supine position on the catheterization table. Make sure the arm (either left or right) is extended fully and position the arm parallel to the body.</li>
		<li>Support the extended arm of the patient by making use of an armrest. Have the patient supinate the lower arm so that the ventral side of the wrist becomes accessible and faces upward.</li>
	</ol>
	</li>
	<li>Access site preparation
	<ol>
		<li>Palpate the radial artery to assess the location suitable for puncture and make sure the wrist is disinfected with either chlorhexidine or povidone-iodine.</li>
		<li>Let the patient overextend their wrist to improve accessibility of the radial artery. Create a sterile field by placing a sterile cover that only reveals the disinfected wrist.</li>
	</ol>
	</li>
	<li>Access site puncture
	<ol>
		<li>Infiltrate the subcutaneous space around the intended puncturing site with 1-2 mL of 1% lidocaine solution.</li>
		<li>Puncture the radial artery directly with a hollow needle (usually present within the sheath kit). Pulsatile backflow through the hollow needle confirms successful puncture of the radial artery.</li>
		<li>Directly afterward, insert a guidewire into the hollow needle. Advance the guidewire for at least 5 cm to ensure arterial access is maintained. Subsequently, retrieve the hollow needle back over the wire.</li>
		<li>Flush the sheath and side port before introducing it to ensure there is no air within the system. Introduce a 5 or 6 Fr sheath over the wire and then remove the guidewire and dilator. Introduce a pigtail catheter through the sheath.</li>
	</ol>
	</li>
	<li>Advancing catheter
	<ol>
		<li>Advance the pigtail catheter using direct fluoroscopy. Use an anterior-posterior (0&#176;/0&#176;) view.</li>
		<li>Position the pigtail catheter in the Non-Coronary Cusp (NCC). Check the positioning of the pigtail catheter by performing contrast injections of 10 mL of contrast medium in a cusp-overlap view. The tip of the pigtail catheter should be situated in the NCC.</li>
	</ol>
	</li>
	<li>Access site closure
	<ol>
		<li>Once the TAVI prosthesis has been deployed and the primary access site has been closed, achieve hemostasis by removing the pigtail catheter and by placing a compression device.</li>
		<li>Let the device exert compression for at least 2 h and afterward slightly release pressure every 10-15 min.</li>
		<li>To prevent access site bleeding, make sure the patient minimizes arm use during the first 24 h. An arm sling can assist in achieving this.</li>
		<li>Once the compression device is completely deflated, remove the device and cover the puncture site with an island dressing or bandage.</li>
	</ol>
	</li>
</ol>

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</ol>

Marleen H. van Wely reported receiving personal fees from Abbott Vascular and Boston Scientific Corporation. Robert Jan van Geuns reported receiving consulting and speaker's fees from Abbott Vascular, AstraZeneca, Sanofi SA, Amgen Inc., and InfraRedx Inc. and receiving institutional research grant funding from Amgen Inc., InfraRedx Inc., AstraZeneca, and Sanofi SA. Robin H. Heijmen has been a consultant for Medtronic. Niels van Royen has received research funding from Abbott, Philips, Medtronic and Biotronik, has served as a consultant for RainMed, Castor and Medtronic and received speaker fees from Abbott and Bayer. The other authors do not have any disclosures to report.

Access site-related bleeding remains one of the most prevalent complications after TAVI1,2. The method described in this paper for upper-extremity access helps to reduce secondary access site-related bleeding. Additionally, the procedures described in this paper reduce time to mobilization in case a patient requires a temporary pacing lead after the procedure, either for active pacing or serving as backup. Furthermore, a non-statistically significant difference i...

Despite a reduction in sheath sizes and improvements in percutaneous closure over the years, access site-related bleeding remains a prevalent complication after transcatheter aortic valve implantation (TAVI)1,2. While the primary access, used for inserting the valve prosthesis, has been the main target for reducing these complications, a significant proportion of access site bleeding is related to the secondary access sites3,4. These access sites include secondary arterial access, which is required for invasive hemodynamic measurements and angiographic guidance, and a third (venous) access site, which is needed for patients requiring a temporary pacing lead. Retrospective studies have reported on the feasibility of using the radial artery as secondary arterial access during TAVI, showing a reduced incidence of bleeding complications related to this secondary access site3,5. However, randomized data were&#160;lacking.
In addition to angiographic guidance, rapid ventricular pacing is usually required for accurate valve deployment. Additionally, rapid ventricular pacing is required during pre- or post-dilatation. Rapid ventricular pacing minimizes cardiac output and creates a short window of opportunity in which the operator can deploy the valve prosthesis. Previously, to perform rapid pacing, a temporary pacing lead was inserted in all TAVI patients using either the femoral or the jugular vein. This temporary pacing lead also provides backup in case high-degree conduction disturbances occur. These disturbances are encountered frequently due to the anatomical location of the conduction pathways near the aortic annulus6,7. Despite these risks, pacing over the left ventricular stiff wire proved an effective and safe strategy for rapid ventricular pacing in patients with a low pre-procedural risk of conduction disturbances8,9. This approach concomitantly omitted the need for a third access site in eligible patients. Despite these advancements, temporary pacing leads are still typically placed in patients with a high pre-procedural risk of conduction abnormalities10, resulting in an increased risk of access site-related complications. In particular, the jugular or femoral veins, which are commonly used for pacing lead insertion, are prone to access site-related bleeding11. Moreover, jugular or femoral venous access for temporary pacing lead insertion precludes early mobilization to prevent lead dislocation after the procedure.
In an attempt to address and improve both secondary access sites, the TAVI XS trial investigated whether using an upper-extremity approach for secondary access would result in fewer clinically relevant access site-related bleeding complications12. Aside from investigating secondary radial access, the TAVI XS trial aimed to investigate an upper-extremity approach for temporary pacing lead placement. This novel strategy had previously been investigated in a prospective registry, which showed that its use is safe and effective11. Moreover, the use of this upper-extremity approach for temporary pacing lead placement is associated with a significantly shorter time to mobilization compared with a femoral or jugular approach. This is particularly relevant as prolonged immobilization is a known risk factor for delirium13,14, which is subsequently associated with an increased duration of hospitalization and higher rates of rehospitalization and mortality15,16.
The TAVI XS trial was a pragmatic study with few exclusion criteria, affirming the scope of the presented approach. All transfemoral TAVI patients, with no evident contraindications for radial- or femoral arterial access (such as known occlusion) and no contraindications for upper-arm or femoral venous access (such as a known disruption of vascular patency) and no intended use for a cerebral embolic protection device, were deemed eligible for participation. As the results of the aforementioned registry and clinical trial show the possible benefit of this approach, the main objective of this protocol is to describe the upper-extremity approach as investigated in the TAVI XS trial, in greater detail. This protocol focuses mainly on the upper-extremity venous access for temporary pacing lead insertion, as most operators will be unfamiliar with this approach. The method presented is readily applicable to most TAVI patients, directly reduces access site-related bleeding complications, and reduces time to mobilization in patients requiring extended pacing. It should, therefore, be considered in all eligible transfemoral TAVI patients.

<table><tbody><tr><td>Bordered island dressing (any size covering the access site)</td><td>N/A</td><td>N/A</td><td>N = 1; used for access site closure after sheath removal</td></tr><tr><td>Chlorhexidine 0.5% in 70% ethanol solution</td><td>N/A</td><td>N/A</td><td>Used for disinfecting the access site</td></tr><tr><td>Compression device (TR Band)</td><td>Terumo</td><td>TRB24-REG</td><td>N = 1; used for access site closure</td></tr><tr><td>Empty sterile cup (in our case a 60 mL cup is used)</td><td>N/A</td><td>N/A</td><td>N = 1; used for holding the lidocaine 1%</td></tr><tr><td>Flow directed 5 Fr pacing catheter (Pacel)</td><td>Abbott Laboratories</td><td>401761</td><td>N = 1; temporary pacing lead</td></tr><tr><td>Gauze (in our case a 7,5 * 7,5 cm gauze)</td><td>N/A</td><td>N/A</td><td>N = 5-10; used for disinfection</td></tr><tr><td>Hollow needle: 21 Gauge * 5 cm</td><td>N/A</td><td>N/A</td><td>N = 1; used for filling the syringe with either sodium-chloride or lidocaine</td></tr><tr><td>Injection needle: 18 Gauge * 4 cm</td><td>N/A</td><td>N/A</td><td>N = 1; used for lidocaine infiltration</td></tr><tr><td>Introducer sheath kit 6 Fr (Glidesheath Slender - including hollow needle, guidewire, dilator and sheath)</td><td>Terumo</td><td>RM*RS6J10PQ</td><td>N = 1; used for creating a 6 Fr lumen with side-port</td></tr><tr><td>Lidocaine 1% injection fluid</td><td>N/A</td><td>N/A</td><td>10 mL; used for local anesthesia</td></tr><tr><td>Sterile 0.9% sodium-chloride solution</td><td>N/A</td><td>N/A</td><td>Liberal ~50 mL; used for flushing the sheath and side-port</td></tr><tr><td>Sterile coat for the operator</td><td>N/A</td><td>N/A</td><td>N = 1; used for sterile placement of pacing lead</td></tr><tr><td>Sterile cover for patient 110 * 90 cm with 12,5 cm opening. Other sizes work as well as long as the opening is the right size to reveal the upper arm.</td><td>N/A</td><td>N/A</td><td>N = 1; used for creating sterile workfield</td></tr><tr><td>Sterile cover for patient with an opening only revealing the disinfected wrist</td><td>N/A</td><td>N/A</td><td>N = 1; used for creating sterile workfield</td></tr><tr><td>Sterile cover for workfield 75 * 75 cm</td><td>N/A</td><td>N/A</td><td>N = 1; used for creating sterile workfield (tray table)</td></tr><tr><td>Sterile cup (in our case a 60 mL cup is used)</td><td>N/A</td><td>N/A</td><td>N = 2; used for holding sterile sodium-chloride (0.9%) and for holding the lidocaine 1%</td></tr><tr><td>Sterile disposable adapters for temporary pacing lead</td><td>Fiab</td><td>PG922/2TPS2</td><td>N = 1; one set of two pieces (red and black)</td></tr><tr><td>Sterile gloves for the operator</td><td>N/A</td><td>N/A</td><td>N = 1; used for sterile placement of pacing lead</td></tr><tr><td>Sterile ultrasound gel (usually included with probe cover)</td><td>Exact Medical</td><td>E6434</td><td>N =1; used for working sterile with ultrasound</td></tr><tr><td>Sterile ultrasound probe cover 15*244 cm</td><td>Exact Medical</td><td>E6434</td><td>N =1; used for working sterile with ultrasound</td></tr><tr><td>Syringe (10 mL)</td><td>N/A</td><td>N/A</td><td>N = 2; used for both sodium-chloride and lidocaine</td></tr><tr><td>Temporary pacemaker device</td><td>local preference</td><td>local preference</td><td>Used for pacing</td></tr><tr><td>Tourniquet (Disposable, 47 cm * 2.5 cm)</td><td>E.g. Eikon Medical Solutions</td><td>Unkown</td><td>N =1; used for improving success rate of venous puncture by compressing the vein</td></tr><tr><td>Transparent film dressing (10 * 12 cm)</td><td>3M</td><td>DH888848289</td><td>N = 2; usually one piece would suffice, sometimes two are required</td></tr><tr><td>Ultrasound device with vascular probe</td><td>local preference</td><td>local preference</td><td>Used for visualization of upper arm vasculature&amp;nbsp;</td></tr><tr><td>Universal MYO/Wire disposable patient cable (1.8m)</td><td>A&amp;amp;E Medical corp.</td><td>119-535</td><td>N = 1; used for connecting lead to pacemaker device</td></tr></tbody></table>

upper-extremity approach for secondary access in transfemoral transcatheter aortic valve implantation

Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) requires multiple access sites, each with a potential risk of access site-related bleeding complications. While most bleeding events occur at the primary TAVI access site, a significant number of bleeding events originate from the secondary access sites. Additionally, a temporary pacing lead prevents early mobilization after TAVI, while prolonged immobilization is associated with an increased rate of post-procedural complications such as delirium and infection. Using alternative secondary access sites may reduce the incidence of access site-related complications and facilitate early mobilization after TAVI. This protocol describes an upper-extremity approach, as recently investigated in the TAVI XS trial, and aims to provide a comprehensive overview of the methodology. For this approach, the radial artery is used for diagnostic access, and the upper arm veins (basilic, cephalic, or brachial vein) are used for temporary pacing lead insertion. To enhance reproducibility, a step-by-step protocol was created on how to perform an upper-extremity secondary access approach during transfemoral TAVI. It was previously demonstrated that an upper-extremity approach for secondary access results in significantly fewer clinically relevant secondary access site-related bleeding complications. Additionally, the approach reduces the time to mobilization for patients who require a pacing lead for an extended period of time. Due to the pragmatic nature of the aforementioned study, the protocol presented here is readily applicable to the majority of transfemoral TAVI patients. The upper-extremity approach reduces periprocedural complications in TAVI patients and may facilitate early mobilization. The presented approach is the next step in minimizing the invasiveness of transfemoral TAVI and should be considered in all eligible TAVI patients.

Step 2 has previously been investigated in both a prospective registry and a randomized clinical trial11,17. The prospective registry demonstrated that using the upper arm veins for temporary pacing lead placement results in a shorter time to mobilization when compared to the conventional approach using the femoral or jugular vein. Moreover, the incidence of access site bleeding was significantly lower11. Time to mobilization remained sign...

An upper-extremity approach for secondary access during transfemoral transcatheter aortic valve implantation is associated with fewer secondary access site-related bleeding complications and reduces time to mobilization in patients requiring extended pacing. This protocol aims to provide an extensive overview of the upper-extremity approach and guide operators in adopting this methodology.

Transcatheter aortic valve implantation (TAVI) requires multiple access sites, each with a potential risk of access site-related bleeding complications. ...

Our goals include refining our TAVI practices and improve overall procedural outcome. One of our aims was to reduce exercise complications and facilitate early mobilization and a quick rehabilitation. Inserting a temporary pacing lead in a manner that allows for early mobilization does not only enhance clinical outcomes, but also increases satisfaction among both patients and nursing staff.Our current goal is to enhance diagnostic accuracy for para valvular regurgitation. By utilizing invasive hemodynamic measurements and creating a real time algorithm, we aim to more accurately detect and reduce para valvular regurgitation. To begin, instruct the patient to lie in a supine position on the catheterization table.Fully extend the patient's left arm at a 90 degree angle relative to the thorax, maintaining the arm in the same vertical plane, and support the arm with an armrest. Instruct the patient to overextend and supinate the arm to present the medial ventral side of the upper arm to the operator. Disinfect the entire upper arm, using either chlorhexidine or povidone iodine, to prepare the access site and wrap a tourniquet around the upper arm as proximally as possible to enhance vein visibility.Place a sterile cover that exposes only the disinfected upper arm to create a sterile field. Now prepare for ultrasound guided puncture by using a vascular probe, covering it with ultrasound gel and a sterile probe cover and applying sterile ultrasound gel to the access site. Use ultrasound to locate a suitable vein for puncture, typically found 5 to 10 centimeters proximal to the elbow crease.Identify the basilic vein on the medial ventral side, or the cephalic vein on the lateral side as common choices. Choose a vein based on depth, giving preference to superficial veins, and select a vein with a larger diameter for easier puncture. After selecting a suitable vein, use the ultrasound probe to compress it and confirm it is a vein by ensuring it collapses under pressure.Infiltrate the subcutaneous tissue at the desired access site with one to two milliliters of 1%lidocaine solution. Using direct ultrasound guidance, puncture the vein with a hollow needle from the six French sheath kit and confirm backflow. Immediately insert a guide wire through the hollow needle and advance it.Then, remove the tourniquet and withdraw the hollow needle over the wire. Next, flush the sheath and side port thoroughly to ensure no air remains in the system. Introduce the six French sheath over the guide wire, and then remove the guide wire and dilator creating a six French lumen.Use a five French flow directed pacing catheter with the balloon and introduce it deflated through the sheath and advance the pacing lead further. Use fluoroscopy in an anterior posterior zero degree view to guide the pacing lead toward the right ventricle. Continue advancing the pacing lead so it naturally follows the vascular path without resistance.Once the lead tip reaches the subclavian vein, inflate the balloon to help steer it into the right ventricle. To pass through the tricuspid valve, rotate the pacing lead and guide the balloon tip through the valve while inflated. After the lead contacts the right ventricular apex, deflate the balloon.When the pacing lead is properly positioned in the right ventricle, connect the electrode plugs to their corresponding ports on the adapter. Perform a capture threshold test by pacing at 20 beats per minute above the intrinsic heart rate at maximum pacemaker output. Gradually reduce the output amperage until mal capture is observed, indicated by a regular heartbeat or drop in heart rate below the pacemaker setting.Ensure that the pacemaker output setting exceeds at least twice the measured threshold value. If the threshold exceeds 3 mA reposition the pacing lead to achieve a lower threshold. Finally, remove the sterile cover of the temporary pacing lead and fixate it using a large transparent film dressing that covers the access site and approximately 10 centimeters of the external portion of the pacing lead.In the trial, 238 patients were randomized between the upper extremity and the lower extremity cohort for secondary access. Clinically relevant bleeding events were significantly lower in the upper extremity group compared to the lower extremity group. When the upper extremity approach was used, time to mobilization was significantly shorter in patients requiring extended pacing or temporary pacing lead backup at around 530 minutes versus 1, 415 minutes for the lower extremity group.

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Research

JoVE Journal

Medicine

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Learn an upper-extremity approach for secondary access in transfemoral TAVI using ultrasound-guided venous puncture and temporary pacing lead insertion. This technique reduces bleeding complications and enables faster patient mobilization.

Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation

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