Palliative bidirectional Glenn anastomosis for unresectable metastasis in the right ventricle from renal cell carcinoma 16 years after nephrectomy

plantation relative to the transfemoral approach. A patent left internal thoracic artery graft is probably a contraindication to a left axillary approach. The potential to compromise innominate artery flow is a relative contraindication to the right axillary approach. The trans–axillary artery approach offers an additional tool in the new armamentarium for the treatment of aortic stenosis in patients who are candidates for TAVI but who have significant respiratory dysfunction and problematic iliofemoral access precluding the other available techniques. We also believe that it offers some advantages relative to the transfemoral and transapical approaches and is worthy of evaluation in a broader patient population as an alternative access route. References 1. Webb JG, Chandavimol M, Thompson C, Ricci DR, Carere R, Munt B, et al. Percutaneous aortic valve implantation retrograde from the femoral artery. Circulation. 2006;113:842-50. 2. Ye J, Cheung A, Lichtenstein SV, Pasupati S, Carere RG, Thompson CR, et al. Six-month outcome of transapical transcatheter aortic valve implantation in the initial seven patients. Eur J Cardiothorac Surg. 2007;31: 16-21. 3. Grube E, Schuler G, Buellesfeld L, Gerckens U, Linke A, Wenaweser P, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the secondand current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome. J Am Coll Cardiol. 2007;50:69-76. 4. Cribier A, Eltchaninoff H, Tron C, Bauer F, Agatiello C, Sebagh L, et al. Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis. J Am Coll Cardiol. 2004;43:698-703. 5. Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, et al. Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis. Circulation. 2007;116:755-63. Brief Communications