10. Crisis Control: Bailout Management for Failed Percutaneous Axillary Artery Closure with Dr. Rajiv Tayal

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CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss bailout management for failed percutaneous axillary artery closure with expert Dr. Raj Tayal. Building on the Data-to-Delivery and Proctor Playbook episodes, this Crisis Control episode walks through a scenario of wide-open extravasation after Perclose failure during right axillary access TAVR. The team covers a stepwise escalation algorithm — from repeat Perclose deployment and serial balloon tamponade with protamine reversal, to hybrid closure with AngioSeal, to covered stent placement with the Viabahn endoprosthesis — and discusses when to call vascular surgery. This episode translates the 2022 SCAI Position Statement bailout recommendations into a practical, cath-lab-ready crisis management framework.

CathMasters is for educational purposes only.

CathMasters is for educational purposes only. Music by Elijah K from Pixabay

Pearls

  1. As long as wire access is maintained across the arteriotomy, the operator retains full bailout capability — the working wire going through the arteriotomy allows for repeat vascular closure device attempt, including Perclose and/or AngioSeal (hybrid closure), while the safety wire positioned in the axillary artery from the secondary access allows for balloon tamponade and/or covered stent deployment. Losing wire access is the true crisis.
  2. If both Perclose sutures fail (snapped or cut), the “post-closure” rescue technique involves reinserting a large sheath, placing two 0.035″ wires side-by-side, removing the sheath, then inserting two 8F sheaths side-by-side for sequential Perclose deployment — maintaining wire access through the second sheath throughout.
  3. A 6Fr sheath will accommodate 5-7 mm Viabahn covered stents while a 7Fr sheath will accommodate up to a 9mm Viabahn covered stent.
  4. When deploying a covered stent from the radial artery without a destination sheath, use vascular markers on the screen to mark the bleeding site, lock the table position, and deploy based on those landmarks — retrograde contrast injection from the radial opacifies the vessel poorly compared to antegrade femoral injection.
  5. Covered stent placement in the 2nd segment of the axillary artery has minimal long-term sequelae — there are no critical branches that, if covered, would cause significant ischemia. Covering the lateral thoracic artery is acceptable; the subscapular artery is less desirable but tolerable. Avoid occluding the suprascapular artery (1st segment).

Notes

1. Initial Assessment: Extravasation After Perclose Failure

  • Bleeding is the most common complication of transaxillary access. Risk increases with larger sheaths, patient age, longer dwell time, tortuosity, urgency, and anticoagulation status. Hemostasis failure can lead to bleeding into the axillary space with possible brachial plexus compression and permanent nerve injury. As the axillary artery is extrathoracic, hemothorax should not occur if vessel puncture was in the correct location.
  • The critical first question after failed closure: do you still have wire access through the arteriotomy and a safety wire in the artery? If yes, the full spectrum of bailout options remains available.

2. Stepwise Escalation Algorithm for Failed Closure

The following algorithm represents a synthesis of the SCAI Position Statement recommendations and Dr. Tayal’s practical approach:

  • Step 1 — Repeat Perclose: If one suture snapped but wire access is maintained, deploy an additional Perclose. This maintains wire access and allows interval assessment. If improvement is seen, proceed with observation.
  • Step 2 — Serial balloon tamponade: Advance the tamponade balloon to the arteriotomy site (not proximal to it), inflate at 4–6 atm with simultaneous external manual compression × 5 minutes → deflate → angiogram. Repeat for a second 5-minute cycle if needed.
  • Step 3 — Protamine reversal + balloon tamponade: Administer protamine, then repeat balloon tamponade × 5 minutes with external pressure. Thrombosis risk from protamine in an 8–10 mm axillary artery is low compared to coronary-sized vessels.
  • Step 4 — Hybrid closure (AngioSeal): If bleeding is minimal and appears to be tract oozing between sutures, deploy an AngioSeal collagen plug. Although this sacrifices wire access through the axillary arteriotomy, the 0.018″ safety wire from the secondary femoral/radial access provides continued bailout capability.
  • Step 5 — Covered stent: If bleeding persists after multiple tamponade cycles, proceed to covered stent deployment (see below).
  • Step 6 — Surgical repair: Reserved for scenarios where covered stent is not feasible or effective (see below).

3. Post-Closure Rescue Technique (Both Percloses Failed)

  • If both sutures are lost (snapped, cut, or pulled through), reinsert a large sheath (12–14F) to tamponade the arteriotomy.
  • Place two 0.035″ wires through the sheath.
  • Remove the sheath with both wires in place.
  • Insert two 8F sheaths side-by-side, one over each wire.
  • Deploy Perclose sequentially through one sheath while maintaining wire access through the other.
  • If post-closure Perclose also fails, pivot to AngioSeal or covered stent via the second sheath.

4. Covered Stent Selection and Deployment

  • Viabahn (W. L. Gore & Associates, Inc.) is the preferred covered stent for axillary artery bailout due to superior apposition and crush resistance in this mobile location. Self-expanding covered stents conform to the artery’s shape and adapt to the dynamic environment of the shoulder.
  • Sizing: oversize by ≥1 mm relative to the artery diameter. For most patients (average axillary artery 6–6.5 mm), a 7 or 8 mm Viabahn covers the majority of cases. A 9 mm is rarely needed.
  • Sheath compatibility: Viabahn 5–8 mm requires a 6–7F delivery system.
  • Delivery route:
    • Radial artery: A standard 6–7F slender sheath accommodates Viabahn up to 8 mm. However, visualization is limited (retrograde injection opacifies poorly). Use vascular markers on the screen to mark the bleeding site, lock the table, and deploy based on landmarks. The SCAI Position Statement recommends a long sheath from the radial approach, as passage of balloons and stents can induce spasm and entrapment.
    • Femoral artery: Preferred for the first 5–10 cases — allows antegrade contrast injection with superior visualization and accommodates larger sheaths/devices. A 7–8F long (90–110 cm) sheath is recommended.
    • Brachial artery: Avoid if possible; reserve for cases requiring stent sizes >8 mm when femoral access is unavailable.
  • Length: Use a 50 mm stent and err on the side of extra length. Attempting to be too precise with a short stent risks needing additional stents proximally or distally.
  • Post-dilation: Avoid if possible — post-dilating a self-expanding stent beyond its intended diameter causes foreshortening. Oversizing at initial deployment is preferable.
  • Branch vessel considerations: In the 2nd segment, covering the lateral thoracic artery is acceptable. The subscapular artery (3rd segment) is less desirable to cover. The suprascapular artery (1st segment) should not be occluded. The vertebral and internal mammary arteries (subclavian) must be avoided, but these are normally far proximal from the access site in the 2nd axillary artery segment.
  • Long-term outcomes: Covered stents in the axillary artery are well-tolerated with minimal long-term sequelae. The PAXA Registry reported secondary closure success in 98% of patients after adjunctive endovascular procedures (including 37 covered stents), with 100% axillary artery patency on follow-up CTA in the Al Adas et al. series.

5. When Covered Stent Is Not Feasible or Effective — Surgical Bailout

  • Covered stent may be infeasible when: (1) the delivery system cannot be advanced (severe tortuosity, spasm), (2) the injury is too proximal (1st segment near the thoracic outlet), or (3) a mechanical complication prevents device extraction (e.g., partially deployed balloon-expandable TAVR valve trapped in the artery as referenced in the podcast episode).
  • In the case described by Dr. Tayal, a balloon-expandable TAVR valve balloon ruptured on annular calcium, leaving a partially inflated valve that could not be fully deployed or withdrawn. The team pulled the device back into the axillary artery, inflated a proximal balloon to control bleeding, and a vascular surgeon performed a cutdown, extracted the device, placed a conduit, and the TAVR was completed successfully through the same artery.
  • Key principle: if the arteriotomy is in the 2nd segment, proximal vascular control can be achieved endovascularly (balloon tamponade), buying time for surgical involvement without catastrophic hemorrhage.
  • Direct surgical repair is preferable in some cases to avoid the risks of stent grafts (side branch occlusion, restenosis, thrombosis, infection, reduced mobility). In most cases, the arteriotomy can be repaired primarily unless there is significant atherosclerotic disease or vessel wall disruption, in which case patch angioplasty or interposition graft may be required.

6. Proactive Measures to Minimize Crisis

  • Notify vascular surgery before the procedure — share the plan, data, and bailout strategy. Collegial pre-procedural communication prevents adversarial dynamics if complications arise.
  • Have Viabahn stents (7 mm and 8 mm) in the room, not in a remote storage location.
  • Experienced operators should achieve a <2–3% failure rate requiring covered stent or surgical conversion. The PAXA Registry reported a 1.5% open conversion rate, and the Al Adas et al. series reported a 6.9% covered stent rate (trending down to 4% in the late cohort with experience).
  • Vascular complications from percutaneous transaxillary access, while reported at higher rates than transfemoral (up to 17% major vascular), do not appear to influence clinical outcomes when managed with proper endovascular techniques and materials.

References

  1. Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(3):100041. doi:10.1016/j.jscai.2022.100041 ⭐ Key Reference
  2. Sherwood M, Allen KB, Dahle TG, et al. SCAI expert consensus statement on alternative access for transcatheter aortic valve replacement. J Soc Cardiovasc Angiogr Interv. 2025;4(3 Part A):102514. doi:10.1016/j.jscai.2024.102514 ⭐ Key Reference
  3. Feistritzer HJ, Dumpies O, Rosseel L, et al. Alternative access for TAVR: a state-of-the-art review and practical guide. JACC Cardiovasc Interv. 2025;18(19):2309-2325. doi:10.1016/j.jcin.2025.08.029 ⭐ Key Reference
  4. Bertoglio L, Conradi L, Howard DPJ, et al. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA Registry. J Vasc Surg. 2022;75(3):868-876.e3. doi:10.1016/j.jvs.2021.08.089 ⭐ Key Reference
  5. Al Adas Z, Uceda D, Mazur A, et al. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg. 2024;79(3):487-496. doi:10.1016/j.jvs.2023.10.048
  6. Koziarz A, Kennedy SA, Awad El-Karim G, et al. Vascular closure devices for axillary artery access: a systematic review and meta-analysis. J Endovasc Ther. 2024;31(5):763-771. doi:10.1177/15266028221147451
  7. Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous large-bore axillary access is a safe alternative to surgical approach: a systematic review. Catheter Cardiovasc Interv. 2020;96(7):1481-1488. doi:10.1002/ccd.29273
  8. Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EuroIntervention. 2022;17(18):1514-1522. doi:10.4244/EIJ-D-21-00549
  9. Palmerini T, Saia F, Kim WK, et al. Vascular access in patients with peripheral arterial disease undergoing TAVR: the Hostile Registry. JACC Cardiovasc Interv. 2023;16(4):396-411. doi:10.1016/j.jcin.2022.12.009
  10. Lederman RJ, Babaliaros VC, Lisko JC, et al. Transcaval versus transaxillary TAVR in contemporary practice: a propensity-weighted analysis. JACC Cardiovasc Interv. 2022;15(9):965-975. doi:10.1016/j.jcin.2022.03.014
  11. Mach M, Okutucu S, Kerbel T, et al. Vascular complications in TAVR: incidence, clinical impact, and management. J Clin Med. 2021;10(21):5046. doi:10.3390/jcm10215046
  12. Xenos ES, Freeman M, Stevens S, et al. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg. 2003;38(3):451-454. doi:10.1016/S0741-5214(03)00553-7
  13. Schäfer U, Ho Y, Frerker C, et al. Direct percutaneous access technique for transaxillary transcatheter aortic valve implantation: “the Hamburg Sankt Georg approach.” JACC Cardiovasc Interv. 2012;5(5):477-486. doi:10.1016/j.jcin.2011.11.014
  14. Bertoglio L, Mascia D, Cambiaghi T, et al. Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair. J Vasc Surg. 2018;68(1):34-40. doi:10.1016/j.jvs.2017.10.076
  15. Gleason TG, Schindler JT, Hagberg RC, et al. Subclavian/axillary access for self-expanding transcatheter aortic valve replacement renders equivalent outcomes as transfemoral. Ann Thorac Surg. 2018;105(2):477-483. doi:10.1016/j.athoracsur.2017.07.017
  16. Ali N, Cunnington MS, Muir D, et al. Transcatheter aortic valve implantation via percutaneous axillary access — a UK registry. Catheter Cardiovasc Interv. 2026;107(4):997-1004. doi:10.1002/ccd.70435
  17. Ooms JF, Van Mieghem NM. Completely percutaneous transaxillary aortic valve implantation under local anesthesia: a minimalist alternative access approach. JACC Cardiovasc Interv. 2019;12(1):e1-e2. doi:10.1016/j.jcin.2018.10.041
  18. Sequeira A, Abreo K. The structure and function of endovascular stents: a primer for the interventional nephrologist. Semin Dial. 2014;27(3):272-282. doi:10.1111/sdi.12225
  19. Chopra A, Modrall JG, Knowles M, et al. Uncertain patency of covered stents placed for traumatic axillosubclavian artery injury. J Am Coll Surg. 2016;223(1):34-41. doi:10.1016/j.jamcollsurg.2016.03.023
  20. DuBose JJ, Rajani R, Gilani R, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785-1792. doi:10.1016/j.injury.2012.08.028
  21. Feldman DN, Armstrong EJ, Aronow HD, et al. SCAI consensus guidelines for device selection in femoral-popliteal arterial interventions. Catheter Cardiovasc Interv. 2018;92(1):E165-E174. doi:10.1002/ccd.27635