title: The "Chimney approach" for transcatheter aortic valve implantation: A strategy for trans axillarian bareback approach in patients with no other access options.
abstract: OBJECTIVE
  to describe the procedural steps and to report the short term follow up of our initial experience with an axillarian bareback Dacron graft based technique that could potentially reduce the rate of vascular and ischemic complications during transcatheter aortic valve implantation in patients with contraindications to trans-femoral approach and with patent left internal mammary arterial graft to left anterior descending coronary artery (LIMA-LAD) or small caliber axillarian/subclavian arteries.
  
  
  RESULTS
  Four patients were treated with TAVI implantation with a trans axillarian bareback approach. Three out of four had a patent LIMA-LAD graft. In three patients, femoral approach was not considered as an option for the presence of diffuse peripheral vascular disease, while in one for the small caliber of iliac-femoral arteries. All procedures were performed under general anaesthesia. No procedural complications occurred.
  
  
  CONCLUSIONS
  In this initial experience, the axillarian bareback approach technique allowed a safe and successful TAVI implant in a subgroup of patients with a high risk of procedural complications due to the presence of a patent LIMA-LAD or vessels of small caliber. Considering the increasing number of patients referred for TAVI, in the next future the axillarian bareback approach could represent a safer alternative to direct cannulation in patients with severe aortic stenosis with no other access options.
authors.affiliation: The Heart Centre, Rigshospitalet, Copenhagen, Denmark.
authors.forename: L
authors.initials: L
authors.lastname: Biasco
authors.affiliation: The Heart Centre, Rigshospitalet, Copenhagen, Denmark.
authors.forename: O
authors.initials: O
authors.lastname: De Backer
authors.affiliation: The Heart Centre, Rigshospitalet, Copenhagen, Denmark.
authors.forename: S
authors.initials: S
authors.lastname: Holme
authors.affiliation: The Heart Centre, Rigshospitalet, Copenhagen, Denmark.
authors.forename: L
authors.initials: L
authors.lastname: Søndergaard
authors.affiliation: The Heart Centre, Rigshospitalet, Copenhagen, Denmark.
authors.forename: A
authors.initials: A
authors.lastname: Jönsson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000628:therapy*; D001365:Axilla; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome
keywords: interventional devices/innovation; percutaneous valve therapy; transcatheter valve implantation