Arterial Site Research Articles

Outcomes After Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting According to Lesion Site: Results From the EXCEL Trial

ObjectivesThe authors sought to determine the extent to which the site of the left main coronary artery (LM) lesion (distal bifurcation versus ostial/shaft) influences the outcomes of revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). BackgroundAmong 1,905 patients with LM disease and site-assessed SYNTAX scores of <32 randomized in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, revascularization with PCI and CABG resulted in similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. MethodsOutcomes from the randomized EXCEL trial were analyzed according to the presence of angiographic core laboratory–determined diameter stenosis ≥50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%). ResultsAt 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs. 14.9%, odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated LM ostial/shaft disease (12.4% vs. 13.5%, OR: 0.90, 95% CI: 0.45 to 1.81; p = 0.77) (pinteraction = 0.65). However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13.0% vs. 7.2%, OR: 2.00, 95% CI: 1.41 to 2.85; p = 0.0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%, OR: 1.18, 95% CI: 0.52 to 2.69; p = 0.68) (pinteraction = 0.25). ConclusionsIn the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft.

Targeting Delivery of Rapamycin with Anti-Collagen IV Peptide Conjugated Fe₃O₄@Nanogels System for Vascular Restenosis Therapy.

Coronary arterial disease (CAD) remains the leading cause of death globally. Although percutaneous coronary interventions (PCI) are most of the important clinical procedure for CAD treating, unfortunately, vascular restenosis is proved as the major drawback of PCI. Because of the complex nature of the restenotic process, the efficacy of drug administration is emphasized. Targeting drug delivery systems become a promising experimental approach for restenosis therapy. Hence, we design and fabricate a thermo/pH-responsive nanogel system with the magnetic inner core as the multifunctional nanocarrier for drug delivery and MRI/fluorescence imaging. To this end, NIPAm-based Fe3O4 core-shell structure nanogel is synthesized as the responsive nanosystem for rapamycin (RAPA) delivery, and the surface conjugation with anti-collagen IV peptide makes the nanosystem an ideal candidate for targeting delivery of RAPA. Based on its stimuliresponsive properties, the nanosystem shows desirable intracellular release behavior of RAPA and significantly reduces the adverse effect of RAPA. The in vitro cytotoxicity evaluations present the biosafety profiles and antiproliferation performance of the drug-loaded nanogels. Meanwhile, the magnetic Fe3O4 inner core shows enhanced T2 weight sensitivity, providing a high potential for imaging-guiding therapy. In the balloon angioplasty model, targeting nanogels are demonstrated accumulation at the injured site of artery. Compared with the non-targeting nanogels, treatment with peptide conjugated nanogels attenuates neointimal hyperplasia more effectively. The biochemical assays further reveal that the enhanced restenosis prevention effect is contributed to the selective release of RAPA at the injured sites of artery, which notably potentiate the nanosystem as a systemically targeting delivered treatment.

Local Evaluation of Variation in Pulse Wave Velocity over the Cardiac Cycle using Single-Element Ultrasound Transducer.

A method and system for single-site measurement of local pulse wave velocity (PWV) and its variation over the cardiac cycle are presented. The proposed system employs a single-element ultrasound transducer and associated custom technology to record arterial diameter and wall thickness waveforms in real-time. Simultaneously acquired blood pressure, diameter and wall thickness parameters were used to evaluate diastolic local PWV (CD) and systolic local PWV (Cs) from an arterial site of interest. The developed prototype system was validated on a cohort of 15 subjects (age $=43\pm 12$ years) that includes normotensives and hypertensives. Cs and CD measurements were obtained from the left carotid artery. A significant difference between carotid Cs and CD $(\Delta \mathrm{C})$ was observed in all recruited subjects (group average $\Delta \mathrm{C} = 0.92\pm 0.76\mathrm{m}/\mathrm{s})$, illustrating the arterial pressure dependency of local PWV. The absolute values of Cs and CD were within a range of 3.39 m/s to 7.5 m/s and 3.12 m/s to 5.82 m/s respectively. Normotensive versus hypertensive group-wise analysis was performed to investigate the degree of variation in the carotid local PWV over a cardiac cycle among different BP categories. Study results demonstrated that the proposed approach has a potential to provide valuable surrogate markers for cardiovascular risk assessment.

Ultrasound-guided thrombin injection in the management of pseudoaneurysm after percutaneous arterial access.

Aim: The purpose of this paper was to evaluate the efficacy of ultrasound-guided percutaneous thrombin injection as a treatment method for arterial access site pseudoaneurysm. Materials and methods: A total of 148 patients with iatrogenic arterial access site pseudoaneurysms were treated in the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin. Of those, 142 pseudoaneurysms were located in the common femoral artery, 3 in the brachial artery and the remaining 3 in the radial artery. The study included 77 woman and 71 men (mean age 64.5 ± 14 years). Patients were qualified for percutaneous thrombin injection after Doppler examination during which pseudoaneurysm size and morphology were assessed as well as the presence of arteriovenous fistula was excluded. Results: In the reported study, 94.8% (128/135) of patients were successfully treated during the initial thrombin injection. Additional 400 IU dose of thrombin after 24 hours was effective in 5 out of 7 patients with recanalization during the follow-up. A total of 98.5% (133/135) of patients were successfully treated with a percutaneous ultrasound-guided thrombin injection. Conclusions: The 10-year experience presented in this study as well as literature reports prove that percutaneous ultrasound-guided thrombin injection is an effective and safe treatment method for iatrogenic arterial access site pseudoaneurysm.

An Accurate Bioimpedance Measurement System for Blood Pressure Monitoring

One potential method to estimate noninvasive cuffless blood pressure (BP) is through measurement of pulse wave velocity (PWV), which can be characterized by measuring the distance and the transit time of the pulse between two arterial sites. To obtain the pulse waveform, bioimpedance (BI) measurement is a promising approach because it continuously reflects the change in BP through the change in the arterial cross-sectional area. Several studies have investigated BI channels in a vertical direction with electrodes located along the wrist and the finger to calculate PWV and convert to BP; however, the measurement systems were relatively large in size. In order to reduce the total device size for use in a PWV-based BP smartwatch, this study proposes and examines a horizontal BI structure. The BI device is also designed to apply in a very small body area. Our proposed structure is based on two sets of four-electrode BI interface attached around the wrist. The effectiveness of our system and approach is evaluated on 15 human subjects; the PWV values are obtained with various distances between two BI channels to assess the efficacy. The results show that our BI system can monitor pulse rate efficiently in only a 0.5 × 1.75 cm2 area of the body. The correlation of pulse rate from the proposed design against the reference is 0.98 ± 0.07 (p < 0.001). Our structure yields higher detection ratios for PWV measurements of 99.0 ± 2.2%, 99.0 ± 2.1%, and 94.8 ± 3.7% at 1, 2, and 3 cm between two BI channels, respectively. The measured PWVs correlate well with the BP standard device at 0.81 ± 0.08 and 0.84 ± 0.07 with low root-mean-squared-errors at 7.47 ± 2.15 mmHg and 5.17 ± 1.81 mmHg for SBP and DBP, respectively. Our results inform future designs of smart watches capable of measuring blood pressure.

Distally Based Peroneus Brevis Muscle Flap for Large Leg, Ankle, and Foot Defects: Anatomical Finding and Clinical Application.

Peroneus brevis muscle flap is a distinguished, distally based safe flap that can be manipulated to cover small defects in the leg and ankle. For large-sized defects, a more distal, larger flap is required either locally or distantly. Forty-two distally based peroneus brevis muscle flaps were elevated in 42 patients (30 males and 12 females) with major lower leg, ankle, and proximal foot defects of 6 to 15 cm in length and 6 to 12 cm in width. Anatomical findings were recorded as number, size, and sources of blood supply, entry sites, the lowermost two arterial supplies, internal distribution of blood supply to the muscle, the relationship between external and internal distribution of the blood vessels, the length of the muscle, the entry site of the main artery, and the splitting of the proximal portion of the peroneus brevis muscle to increase its width to sufficiently cover large defects. The anatomical findings suggested that the muscle can be safely extended to cover a large defect in the leg, ankle, or proximal foot. In addition, the longitudinal splitting of the muscle increases its width by up to three times, making it an excellent long-surviving flap to cover a large defect. A distally based peroneus brevis muscle flap has a rich blood supply and safely reaches the proximal foot, with a secure splitting to cover large defects in the leg, ankle, and proximal foot.

The anatomical relationship between the axillary artery and vein investigated by radial coronary angiography.

To reduce the risk of inadvertent arterial puncture and bleeding, we aimed to define a safe puncture site by demonstrating the relation of the axillary artery and vein. The anatomical course and relation as well as crossover sites of the axillary artery and vein, the presence of small arterial bridges over the axillary vein, and validation of commonly preferred axillary venous puncture sites were determined by simultaneous ipsilateral venography in patients (n=111; 80 men, age 60 ± 10 years) who underwent coronary angiography by radial artery access. The axillary vein was detected at the first costa-clavicular intersection in 62% and at the second anterior and third posterior costal intersection in 60% of the patients. Small arterial bridges over the axillary vein were observed in 77% of the patients and more frequently in females and body mass index ≥25kg/m2 (P=0.034 and P=0.03, respectively). The axillary artery crossed the vein in 24% of the patients and almost always within the region close to the first costa-clavicular intersection site. Our study demonstrated a high crossover rate (24%) of axillary artery and vein and a high degree of variation in the course of axillary vein. Small arterial bridges over the axillary vein were observed in 77% of the patients.

Http://www.ejcvsmed.org/articles/case-report/hybrid-treatment-supravalvular-aortic-stenosis-coronary-ostial-stenosis-familial-hypercholesterolemia/

An arteriovenous fistula (AVF) is a vascular malformation with a direct communication between an artery and a vein and can lead to bleeding, thromboembolic events, aneurysm formation or heart failure. AVF is a rare but potentially harmful complication of cardiac catheterization. The sites of associated artery and vein are important for surgical exposure. We report two cases of femoral AVFs following diagnostic cardiac catheterizations with rather interesting extensions, originating from right deep femoral arteries and draining into right superficial femoral veins in both cases. The tracks were divided and the defects on deep femoral arteries and superficial femoral veins were primarily sutured. Symptoms of the patients, which were mainly edema and pain, relieved after surgeries. Both the patients were discharged without any complications. During cardiac catheterization, the cardiologist should master the anatomy of the femoral puncture site to avoid the complications which can be hazardous and life-threatening such as AV fistula.

Caudal dorsal artery generates hematopoietic stem and progenitor cells via the endothelial-to-hematopoietic transition in zebrafish

Zebrafish hematopoietic stem and progenitor cells (HSPCs) originate from the hemogenic endothelium of the ventral wall of the dorsal aorta (DA) through the endothelial-to-hematopoietic transition (EHT) from approximately 30 to 60 hours post fertilization (hpf). However, whether other artery sites can generate HSPCs de novo remains unclear. In this study, using live imaging and lineage tracing, we found that the caudal dorsal artery (CDA) in the caudal hematopoietic tissue directly gave rise to HSPCs through EHT. This process initiated from approximately 60 hpf and terminated at approximately 156 hpf. Compared with that in the DA, fewer EHT events were observed in the CDA. The EHT events in the DA and CDA were similarly regulated by Runx1 but differentially influenced by blood flow (i.e., the EHT frequency in CDA was affected to a lesser extent when circulation was compromised in the tnnt2a−/− mutant). Therefore, the whole artery, including both DA and CDA, was endowed with the ability to produce HSPCs during a much longer time period. Coincidently, the lineage tracing results indicated that adult hematopoietic cells originated from the embryonic endothelium, and those produced later preferentially colonized the adult thymus. Collectively, our study revealed that the CDA serves as an additional source of hematopoiesis, and it shows similar but not identical properties with the DA.

A refractory hypertensive patient with fibromuscular dysplasia and multicystic dysplastic kidney

The case of a 16-year-old male patient with left renal artery stenosis due to fibromuscular dysplasia (FMD) and an atrophic kidney due to a right multicystic dysplastic kidney (MCDK) who presented with refractory hypertension is reported. On continuous Doppler imaging, the peak systolic velocity (PSV) at the stenotic site of the left renal artery was 404cm/s. The FMD formed a "string-of-beads" appearance on computed tomographic angiography (CTA) and renal artery angiography. Percutaneous transluminal renal angioplasty (PTRA) with a balloon catheter was performed, after which the left renal artery returned to near normal, and his blood pressure decreased to within the normal range. In this case, the main cause of refractory hypertension was considered to have been renal artery stenosis due to left FMD.

Closure of large bore 9 F arterial puncture sites with the AngioSeal STS device in acute stroke patients after intravenous recombinant tissue plasminogen activator (rt-PA)

PurposeThis retrospective analysis was performed to evaluate whether large bore 9 F puncture sites can be safely closed with the 8 F AngioSeal STS device after endovascular stroke procedures in...

Abstract 217: Coronary Artery Disease Locus 1p32.2 Harbors a Flow-Sensitive Endothelial Enhancer that Regulates PLPP3

Genome-wide association studies (GWAS) have identified chromosome 1p32.2 as one of the loci most strongly associated with coronary artery disease (CAD) susceptibility; however, the causal mechanism related to this CAD locus remains poorly understood. A unique feature of atherosclerotic vascular disease such as CAD is that atherosclerosis develops preferentially at arterial sites of curvature, branching, and bifurcation where endothelial cells are activated by disturbed blood flow. Recent investigations by us and others strongly implicate PhosphoLipid PhosPhatase 3 (PLPP3, also known as PhosPhatidic-Acid-Phosphatase-type-2B/ PPAP2B or Lipid Phosphate Phosphohydrolase/LPP3) as the causal gene at this locus. PLPP3 encodes an enzyme that suppresses endothelial inflammation and promotes monolayer integrity by hydrolyzing the bioactive lipid lysophosphatidic acid (LPA). Our studies demonstrated that PLPP3 is significantly reduced in vascular endothelium exposed to disturbed flow in vitro and in vivo, as the result of increased miR-92a and reduced KLF2, when compared to cells subjected to unidirectional blood flow. In addition, CAD risk allele at rs17114036 located in 1p32.2 locus is associated with reduced PLPP3 expression in an endothelium-specific manner, shown by expression quantitative trait locus (eQTL). Employing Transposase-Accessible Chromatin using Sequencing (ATAC-Seq), ChIP-Seq, CRISPR/Cas9-based genome editing, luciferase reporters, and allelic imbalance assays, we report here that CAD SNP rs17114036 is located in an endothelial enhancer that is dynamically activated by athero-protective unidirectional flow and deletion of this enhancer causatively reduces PLPP3 expression in vascular endothelium. In addition, CAD risk allele at rs17114036 is associated with reduced activity of this enhancer and its response to unidirectional flow. These results described a new molecular mechanism by which human genetic variance and mechano-transduction converge on critical vascular functions related to atherosclerosis. Moreover, we have engineered innovative polymeric nano-carriers that preferentially target inflamed endothelium and deliver therapeutic nucleotides that intervene in miR92a-PLPP3 signaling in animal models of atherosclerosis.

Concomitant Polymyalgia Rheumatica and Large-Vessel Vasculitis Visualized on 18F-FDG PET/CT.

Polymyalgia rheumatica (PMR) and large-vessel vasculitis (LVV) are related rheumatic diseases which are occasionally present concomitantly. PMR is characterized by synovitis and bursitis. In LVV, inflammation of the blood vessel wall is seen. Both disorders can be difficult to diagnose since patients often present non-specific symptoms and results of blood tests. The non-specific symptoms cannot always be distinguished from symptoms indicating an occult malignancy. We present a case of PMR and LVV in a Scandinavian man visualized on [18F]-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) with the presentation of typically affected sites of joints and arteries and with the same imaging modality ruling out occult malignancy.

Is the Occlusion Site of the Lenticulostriate Artery Identified on Admission Related to Clinical Prognosis in Patients with Lacunar Stroke?

The mechanism of lacunar stroke (LS) is rather speculative due to the lack of neuropathological evidence in clinical practice. To explore the significance of the occlusion site of the lenticulostriate artery (LSA) to this mechanism, we investigated the characteristics and prognosis of patients with LS with proximal occlusions. We studied 202 patients with acute LS in the region of the LSA. The presumed occlusion site of the LSA was assessed on coronal, diffusion-weighted magnetic resonance images. Based on the distance from the basal surface of the hemisphere to the proximal site of the lacunar infarct, patients were divided into 3 groups: proximal, middle, and distal site occlusions, and their characteristics and outcomes were compared. White blood cell counts, blood glucose, hemoglobin A1c, low-density lipoprotein cholesterol, triglyceride, and admission National Institutes of Health Stroke Scale score were statistically different among the 3 groups. In multivariate analysis, both high levels of white blood cells (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.01-1.33) and triglyceride (OR, 1.31; 95% CI, 1.09-1.61) were positively related to the proximal occlusion site. Proximal occlusion (OR, 3.98; 95% CI, 1.06-16.11) was related to poor outcome at discharge. Proximal occlusion of the LSA was independently related to elevated triglyceride and white blood cell counts. Patients with LS with proximal LSA occlusion had severe neurological deficits both on admission and at discharge.

Techniques of Impella removal while preserving arterial access

Preservation of the arterial access site after removal of large caliber mechanical circulatory devices (MCD) can be challenging. In this paper, we describe two novel techniques and review the current literature focusing on the maintenance of arterial access after Impella removal.

Transcatheter mitral valve intervention: an emerging treatment for mitral regurgitation.

Mitral regurgitation (MR) is a valvular heart disease associated with significant morbidity and mortality. Transcatheter mitral valve intervention (TMVI) repairs or replaces the mitral valve through small arterial and venous entry sites and so avoids risks associated with open heart surgery. Transcatheter devices targeting components of the mitral apparatus are being developed to repair or replace it. Numerous challenges remain including developing more adaptable devices and correction of multiple components of the mitral annulus to attain durable results. The mitral valve apparatus is a complex structure and understanding of the mechanisms of MR is essential in the development of TMVI. There will likely be a complementary role between surgery and TMVI in the near future.

Lipoprotein(a) level associates with coronary artery disease rather than carotid lesions in patients with familial hypercholesterolemia.

Lipoprotein(a) [Lp(a)] level is a novel risk factor for atherosclerotic cardiovascular disease in patients with familial hypercholesterolemia (FH), while its impact on the different sites of arteries remains undetermined. We aim to examine the associations of Lp(a) levels with coronary and carotid atherosclerosis in patients with heterozygous FH (HeFH). A total of 148 patients with HeFH who have received carotid ultrasonography and coronary angiography due to chest pain were enrolled. Plasma Lp(a) was measured using immunoturbidimetric method. Finally, the associations between Lp(a) and coronary as well as carotid lesions were evaluated. Patients with Lp(a)≥300mg/L had similar carotid intima-media thickness (IMT, 0.782±0.16mm vs 0.798±0.18mm, P=.579) and plaque prevalence (66.7% vs 65%, P=.833) compared to those with Lp(a)<300mg/L, but had a higher prevalence of coronary artery disease (CAD, 69.7% vs 50.0%, P=.016) and higher Gensini score (GS, median 27 vs 3, P=.006). Moreover, no correlations were found between carotid mean IMT with either Lp(a) level or Lp(a) year score, while positive relation of Lp(a) with GS did. Multivariate regression analysis revealed that Lp(a), Lp(a) year score, and Lp(a)≥300g/L were all independent predictors for the presence of CAD (OR=4.99, P=.007; OR=4.73, P=.009; OR=4.46, P=.006, respectively) but not for carotid plaques. This study suggested that Lp(a) level was associated with the presence and severity of CAD but not with carotid atherosclerosis in patients with HeFH.

Experience With the Axillary Artery as an Arterial Cannulation Site in Patients With Acute Type A Aortic Dissection

The optimal arterial cannulation site in patients undergoing surgical management of acute type A aortic dissection (ATAAD) remains controversial. The axillary artery is rarely involved in the dissection process, provides antegrade flow in the descending aorta and minimises intraoperative malperfusion. The purpose of this study is to evaluate a single surgeon's experience of axillary artery cannulation for ATAAD repair. All consecutive patients over a 15-year period having surgical repair of ATAAD were included in this study. There were 55 patients with a mean age of 67years. The most common risk factors were hypertension (83.6%), connective tissue disease (7.3%) and a bicuspid aortic valve (7.3%). Axillary artery cannulation was performed on 50 patients (90.9%) and was contraindicated in the remaining five patients. Forty-nine patients survived to 30days with a 10.9% 30-day mortality rate. There was one confirmed stroke (1.8%) and no new malperfusion noted postoperatively. There were no major axillary artery complications or new dissection related to cannulation. We attribute these results, which are lower than those reported in the International Registry of Acute Aortic Dissection (IRAD) database, to axillary artery cannulation providing antegrade flow in the descending aorta from the outset and reducing intraoperative malperfusion. We believe this technique offers a cerebroprotective advantage and also facilitates selective antegrade cerebral perfusion (SACP) when aortic arch replacement is required. We believe the axillary artery is the ideal cannulation site of ATAAD and helps to reduce mortality and neurological complications in this high-risk group of patients.

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.