The development of catheter-based treatment for structural heart disease and the limitations of percutaneous femoral artery access for large bore catheters have led to a recent growth in the use of alternative access sites. In this chapter, we describe the cutdown approach for femoral, axillary, direct aortic, and transapical access. For a description of percutaneous left ventricular apical and transcaval access the reader is referred to chapter 3.

The common femoral artery (CFA) is localized with ultrasound, and the site is marked on the skin. A 3-cm vertical incision is made on the skin just above the inguinal crease with a scalpel (FIGURE 5.1), the subcutaneous tissue is divided with electrocautery, and the inguinal ligament is exposed. A soft tissue retractor is used for lateralmedial retraction, and a handheld retractor is used to retract the inguinal ligament cranially (FIGURE 5.2). The CFA is localized by palpating the pulse, by feeling for a calcified artery, or with the sterile ultrasound probe. The fascia lata is incised vertically, and the CFA is exposed along its anterior surface (FIGURE 5.3). The artery is palpated to identify the optimum location for arterial access. Preferably, the anterior surface at the access site is free of calcified plaque, and there is a soft portion of the artery for clamping for control proximal and distal to the proposed arteriotomy. The distal external iliac artery (EIA), CFA, superficial femoral artery (SFA), and profunda femoris artery (PFA) can be exposed through this incision. The preferred access site is via the CFA, at or just cranial to the bifurcation of the SFA and PFA. The soft tissue is dissected away from the artery circumferentially cranial to the access site and an umbilical tape is passed around the CFA with a right angle clamp (FIGURE 5.4). The common femoral vein is medial to the CFA, the femoral nerve is lateral, and these are avoided by dissecting directly on the surface of the arteries. The SFA and PFA are dissected free, and umbilical tapes are passed around the SFA and PFA for distal vascular control. The profunda femoris vein courses between the SFA and PFA at the bifurcation and can be avoided with careful dissection but may be ligated if necessary.

If the CFA is severely calcified, the inguinal ligament can be elevated with the retractor or partially divided to expose the EIA more proximally. Care is taken to identify and preserve the medial and lateral collateral arteries, and these can be controlled with vessel loops if more proximal access is needed. A vein branch crosses anterior to the distal EIA just cranial to the inguinal ligament and should be ligated and divided if more proximal control is needed. The soft tissue is circumferentially dissected away from the artery above and below the access site and encircled with umbilical tapes for vascular control to allow proximal and distal clamping of the artery for repair of the arteriotomy site if a soft area of the artery can be identified for clamping.

If the CFA and EIA are severely calcified and there is not an adequate location for clamping, a purse-string 5-0 Prolene suture can be used to control and close the arteriotomy site. The purse-string suture is placed in the soft area of the anterior artery before access and must be wider than the diameter of the sheath to be used (FIGURE 5.5).

The artery lumen is accessed with a needle directly, and the guide wire is advanced and the needle removed. The artery is sequentially dilated over the wire, and the catheter is placed and anchored to the skin. At the completion of the endovascular procedure, the sheath is removed and the arteriotomy is closed. If a purse-string suture was placed before the arterial access, the sheath and wire are removed and the purse-string suture is tied to close the arteriotomy (FIGURE 5.6). If the artery is soft enough to clamp, the SFA and PFA are each occluded with a vascular clamp and gentle traction is placed on the umbilical tape proximal to the arteriotomy.

The catheter is gently withdrawn from the artery, and a vascular clamp is used to occlude the artery proximal to the arteriotomy. The edges of the access site in the artery are debrided as necessary to approximate all 3 layers of the artery. The arteriotomy is then closed directly with 5-0 Prolene sutures in an interrupted or running fashion, everting the edges of the arteriotomy for endothelial-to-endothelial approximation. The vascular clamps are each flashed to flush any thrombus or debris from the artery and deair the vessels, and the knots are tied. The clamps are removed, restoring distal flow. The quality of the anastomosis is evaluated with Doppler of the distal vessels and arteriography if needed.

Protamine sulfate is given to reverse the heparin. Hemostasis is ensured. The fascia is approximated with running 2-0 absorbable sutures. The subcutaneous tissue is closed with running 2-0 absorbable sutures. The subdermal and subcuticular tissues are then closed with absorbable sutures, and dry sterile dressings are applied.

A 3- to 4-cm incision is made with a knife 3 cm caudal and parallel to the clavicle, medial to the deltopectoral groove (FIGURE 5.7). The incision is carried down through the subcutaneous fat, and the pectoralis major muscle is identified. The pectoralis major muscle is divided along its fibers and retracted (FIGURE 5.8). The axillary artery pulse is palpated to guide the direction of the dissection. The soft tissue between the pectoralis muscles is divided, exposing the pectoralis minor muscle. The pectoralis minor muscle may be divided partially or completely (FIGURE 5.9) or left intact and retracted laterally. The axillary vein is superficial and caudal to the artery. The clavipectoral fascia is divided along the superior edge of the axillary vein exposing the axillary artery (FIGURE 5.10). The brachial plexus is usually located cranial and deep to the axillary artery and care must be taken to avoid the branches of the brachial plexus. The axillary artery is bluntly dissected free of the surrounding soft tissue and encircled with vessel loops. The thoracoacromial artery, and its branches are usually preserved and controlled with a vessel loop but can be divided if obstructing the exposure (FIGURE 5.11).