Transaxillary TAVI (subclavian access): a Cath Lab 101 guide
Reviewed by Rodnie Oro, cath lab charge nurse · Last reviewed: October 2026 · Education only, not medical advice
Transaxillary TAVI in one minute
What it is: TAVI replaces a narrowed aortic valve using a catheter. Transaxillary TAVI delivers the new valve through the axillary artery, just below the collarbone (usually on the left), instead of the groin, when the leg arteries are too small or diseased.
Who it is for: people with severe aortic stenosis chosen for TAVI by a heart team, whose CT shows the femoral route is unsuitable and whose axillary/subclavian artery is large and healthy enough.
Main risks: bleeding or injury at the axillary artery, damage to the nerves of the arm, stroke, heart block needing a pacemaker, and the usual TAVI risks. Your team will explain your own risk.
Usually: under general anaesthetic or sedation, in a cath lab or hybrid theatre, about 1.5 to 2.5 hours, often home after a few nights.
On this page: What is transaxillary TAVI? · Who is it for? · When is it done? · Step by step · Recovery · Risks · Kit list · First time in the lab? · FAQ
(1) Aortic stenosis: calcified leaflets with a small opening. (2) After TAVI: a new valve sits inside the old one.
What is transaxillary TAVI?
The aortic valve lets blood leave the heart into the aorta. In aortic stenosis, it becomes stiff and narrowed, usually from calcium build-up with age, causing breathlessness, chest pain, dizziness or blackouts. TAVI (transcatheter aortic valve implantation) places a new valve inside the old one using a catheter, without open-heart surgery. See the main TAVI guide.
Most TAVIs are done through the femoral artery in the groin (transfemoral). In some people the leg and pelvic arteries are too narrow, diseased, twisted or heavily calcified for the large delivery system. An alternative access route is then needed. The main options are transaxillary/subclavian (under the collarbone), transcarotid (the neck), transcaval (from the femoral vein into the aorta), and surgical routes through the chest wall. The heart team chooses the route using CT.
In transaxillary TAVI, the delivery system enters the axillary artery, which runs from below the collarbone into the armpit, and travels through the subclavian artery to the aorta and the aortic valve. The left side is often preferred because its angle to the aortic valve suits most delivery systems, but the right is used in some people. It can be done percutaneously (through a needle puncture) or by a small surgical cut-down.
New to the acronyms? See the Cath Lab Abbreviations A–Z.
Route: (1) left axillary artery; (2) subclavian artery; (3) aortic arch; (4) aortic valve.
Who is it for?
NICE guidance on heart valve disease (NG208) recommends TAVI or surgery for severe symptomatic aortic stenosis based on age, risk and a heart team decision, and NICE interventional guidance on TAVI (HTG446) supports its use. The ESC/EACTS valvular heart disease guidelines state that transfemoral access is preferred and that non-transfemoral access may be considered in people unsuitable for surgery and for transfemoral TAVI. The choice between alternative routes depends on the person's anatomy and the centre's experience.
For transaxillary access the CT must show an axillary and subclavian artery wide enough for the sheath, without severe calcium or tortuosity. If a person has had heart bypass surgery using an artery from inside the chest wall (an internal mammary graft) on that side, the opposite side or another route may be chosen to avoid reducing blood flow to the graft.
When is it done?
It is planned. Before it, the team usually arranges:
CT angiography of the heart, aorta and all access arteries
echo, ECG, blood tests and a group and save
a review of blood thinners, as per centre protocol
Step by step
1. Anaesthetic and set-up
Done under general anaesthetic or sedation. A femoral artery or radial artery is used as a second access for angiography, and a femoral vein for a temporary pacing wire. Sizes are per device and operator.
2. Protecting and marking the artery
From the femoral (or radial) access, a catheter is placed in the subclavian artery and an angiogram shows the axillary artery.
A thin wire is passed down into the arm artery and left there. It acts as an X-ray marker and as a safety wire in case a balloon or covered stent is needed.
Heparin is given, dose as per centre protocol.
(1) Safety and marker wire from the groin into the arm artery. (2) Puncture site below the collarbone, in line with the wire.
3. Access and valve delivery
A. Puncture. Using ultrasound and X-ray, the axillary artery is punctured with a small needle below the collarbone, away from the clavicle and in line with the marker wire.
B. Pre-close. Suture-based closure devices are placed before the large sheath, per operator. A small sheath is used to cross the aortic valve and place a stiff wire in the LV.
C. Large sheath. The arteriotomy is dilated and the TAVI sheath (or the delivery system itself, for some valves) is passed carefully under X-ray into the aorta. A balloon in the subclavian artery can be inflated at low pressure during exchanges to control bleeding, per operator.
D. Valve. The valve is positioned and deployed as in transfemoral TAVI.
A: stiff wire in the left ventricle. B: balloon stretch (if used). C: valve positioned. D: valve expanded.
4. Closure
The sheath is removed with a balloon inflated in the subclavian artery for a "dry" field, the pre-placed sutures are tightened, and an angiogram through the second access checks the artery for leaks or narrowing. A balloon or covered stent can be used if needed.
Closure: (1) balloon inflated upstream for a dry field; (2) sutures tied at the puncture; (3) angiogram checks the artery.
Recovery and aftercare
First hours: recovery, often in a coronary care, high-dependency or intensive care area, with checks of the access site, arm pulses and feeling, heart rhythm and blood pressure, as per centre protocol.
Echo and blood tests: before discharge.
Heart rhythm: some people develop heart block and need a permanent pacemaker.
Going home: often after 1 to 3 nights, sometimes longer after alternative access.
Arm: watch for swelling under the collarbone, numbness, weakness or a cold hand in the arm on the access side.
Activity: avoid heavy lifting with that arm for a few weeks, or as advised.
Medicines: antiplatelet or anticoagulant medicines, as per your team's plan.
Driving: DVLA guidance after a percutaneous valve procedure for a car licence is not to drive for 2 weeks; bus and lorry drivers must tell the DVLA. Ask your team.
Call 999 if you have chest pain, sudden breathlessness, fainting, signs of a stroke, or bleeding or swelling at the access site.
After transaxillary TAVI: (1) monitoring and arm checks; (2) echo and bloods; (3) home after a few nights; (4) follow-up.
Risks and complications
Your team will discuss your own risks. Possible problems include:
bleeding, a tear or a blockage at the axillary or subclavian artery, sometimes needing a covered stent or surgery
injury to the brachial plexus nerves, causing arm numbness or weakness (often temporary)
reduced flow to an internal mammary bypass graft on that side
stroke
bleeding or injury to the access artery or vein
heart block needing a permanent pacemaker
a leak around the new valve
kidney strain from contrast dye
rarely, blockage of a coronary artery, damage to the aortic root, or the valve moving
Cath lab kit list (printable)
Barts example kit list
An example from one UK centre, written generically. Every lab has its own protocol, and sizes and doses vary.
Small trolley
femoral sheaths for secondary arterial and pacing access; long sheath and dilator for the axillary artery, sizes per device and operator
diagnostic catheters (pigtail, right coronary and left coronary shapes)
micropuncture kit
snare, per operator
stiff pre-shaped LV wire, per operator
suture-based closure devices (two) and a back-up closure device, per operator
long 0.018" safety/marker wire, per operator
peripheral occlusion balloon for subclavian haemostasis, size matched to the artery, per operator; inflation device; haemostasis valve
radiation shield over the shoulder for the operator
local anaesthetic, heparin and other drugs, as per centre protocol
Valve (crimping) trolley
3-way tap; large syringe for de-airing; syringe for flushing
contrast/saline mix and saline bowls, per device instructions
scissors and forceps
Procedural steps (Barts example)
Anaesthetic; femoral (or radial) secondary access; pacing wire
Subclavian angiogram; 0.018" marker/safety wire into the brachial artery; heparin
Skin marked along the artery under X-ray; ultrasound-guided micropuncture below the collarbone
Two pre-close sutures; small sheath; cross the valve; stiff LV wire
Dilate; large sheath (or sheathless system) into the aorta under X-ray
Valve deployed as for transfemoral TAVI
Balloon inflated in the subclavian artery; sheath out; sutures tied; completion angiogram
First time in the cath lab?
đź’ˇ First-time tip
Set up for the shoulder. Arm position, drapes and the radiation shield are different from a groin case. Keep the safety wire safe. The thin wire in the arm artery must not be pulled out until the end. Balloon ready. Have the occlusion balloon prepared and the inflation device to hand for exchanges and closure. Check the arm. Pulses, colour and movement of the hand are checked after the case. Covered stent available. Know where bail-out stents are kept.
FAQ
Why not the groin?
Because the leg arteries are too narrow, diseased or twisted for the delivery system, as shown on CT.
Will I have a scar?
Usually only a small puncture under the collarbone, unless a surgical cut-down is used.
Can I use my arm afterwards?
Yes, gently. Avoid heavy lifting with that arm for a few weeks, or as advised.
Is it riskier than transfemoral TAVI?
Alternative routes have some extra risks. Your team will discuss your own situation.
Related Cath Lab 101 guides
Sources
All checked on 10 October 2026. Each page's own date is shown where it gives one.
NICE. Heart valve disease presenting in adults: investigation and management (NG208). nice.org.uk/guidance/ng208
NICE. Transcatheter aortic valve implantation for aortic stenosis (HTG446). nice.org.uk/guidance/htg446 (published 26 Jul 2017)
Vahanian A, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2022;43(7):561–632. PubMed 34453165
British Heart Foundation. TAVI. bhf.org.uk
NHS. Aortic valve replacement. nhs.uk
DVLA / GOV.UK. Cardiovascular disorders: assessing fitness to drive (percutaneous valve intervention). gov.uk
Disclaimer
Education only. This page is for general education for healthcare students, cath lab staff and curious readers. It isn't medical advice and doesn't replace advice from your own doctor, heart team or local unit protocols. Equipment and medicines are described generically. No product or manufacturer is recommended. If you think someone is having a heart emergency, call 999.
Disclosure: I work for a company that makes a device used in this procedure. This page is independent education, isn't sponsored or reviewed by any company, and doesn't recommend any product.
All diagrams on this page are original illustrations created for rodnieoro.com.
