Abstract
Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure but may be associated with vascular complications at femoral access sites, particularly in obese patients. This report aimed to describe a case of successful performance of our “double crossover technique” in an obese patient undergoing TF-TAVI with a percutaneous transfemoral intra-aortic balloon pump (TF-IABP). A 75-year-old man presented with heart failure due to a left ventricular ejection fraction of 35% and low-flow, low-gradient severe aortic stenosis. The logistic EuroSCORE and STS-PROM score were 31.38% and 7.311%, respectively. Right TF-TAVI using a 14-Fr expandable sheath and a left TF-IABP using an 8-Fr sheath were scheduled. The patient was obese, with a body mass index of 31.7 kg/m 2 , and we expected access site-related vascular complications to occur. Subsequently, we performed a femoral and brachial crossover technique, called the “double crossover technique,” at the completion of the TAVI procedure: first, for the right common femoral artery (CFA) through the sheath in the left CFA and second, for the left CFA through the sheath in the right brachial artery. In the crossover technique, an 8.0-mm-diameter over-the-wire balloon was advanced to an external iliac artery and was subsequently inflated when the sheath was removed. For the right CFA, a double preclose technique was used with the crossover technique. There was no evidence of access site-related vascular complications following TAVI. The double crossover technique was effective at achieving hemostasis and avoiding access site-related vascular complications in an obese patient undergoing TF-TAVI with a TF-IABP.
Highlights
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A crossover technique is used to achieve hemostasis at femoral access sites.
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The double crossover technique consists of femoral and brachial crossover techniques.
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An obese patient underwent the double crossover technique in TF-TAVI with a TF-IABP.
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There was no evidence of access site-related vascular complications after the TAVI.
1
Introduction
Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure in patients at intermediate and high surgical risk . However, access site-related major vascular complications in TF-TAVI, defined according to the Valve Academic Research Consortium-2 criteria, are not rare and are associated with increased morbidity and mortality .
When TAVI is performed in patients with left ventricular systolic dysfunction, the use of mechanical circulatory support devices during TAVI, such as a percutaneous transfemoral intra-aortic balloon pump (TF-IABP) and an extracorporeal membrane oxygenation device, is considered helpful . Access site-related vascular complications are expected to be frequent in obese patients undergoing TF-TAVI with mechanical circulatory support devices. The femoral crossover technique and radial crossover technique are successful and useful methods of accomplishing hemostasis and avoiding access site-related vascular complications following TAVI .
This report aimed to describe a case of successful femoral and brachial crossover technique, called the “double crossover technique,” in an obese patient undergoing TF-TAVI with a TF-IABP.
2
Case
A 75-year-old man presented with worsening chronic heart failure due to low-flow, low-gradient severe aortic stenosis and was admitted to our hospital. Echocardiography revealed a left ventricular ejection fraction of 35%, an aortic valve area of 0.73 cm 2 , a mean pressure gradient across the aortic valve of 31 mmHg, and no significant aortic regurgitation. The patient had some comorbidities: paroxysmal atrial fibrillation, non-insulin-dependent diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease. There were no findings of ischemic heart disease. The logistic EuroSCORE and the STS-PROM score were 31.38% and 7.311%, respectively.
According to contrast-enhanced computed tomography, there was no contraindication in the bilateral femoral access routes for TF-TAVI ( Fig. 1 ). The minimum lumen diameters of the right external iliac artery (EIA) and the right common femoral artery (CFA) were 7.1 and 5.8 mm, respectively. Right TF-TAVI using a 14-Fr expandable sheath (e-Sheath, Edwards Lifesciences, Irvine, CA, USA) was scheduled with a preprocedural left TF-IABP using an 8-Fr sheath because of left ventricular systolic dysfunction. The patient gave informed consent for the procedure before it began.
The patient received antithrombotic therapy with aspirin 100 mg/day and warfarin. Warfarin was stopped and heparinization was started 3 days before TAVI. Heparinization was stopped 6 h before starting TAVI. The patient was 173 cm tall and weighed 95 kg, with a body mass index of 31.7 kg/m 2 , indicating obesity. As shown by computed tomography, the estimated distance between the skin and the right CFA puncture was at least 70 mm ( Fig. 2 ). We expected that vascular complications at the femoral access sites could occur. Therefore, we performed TF-TAVI using the “double crossover technique” in the following manner, with the patient under general anesthesia ( Fig. 3 ).
Angiography of the aorta to the bilateral iliofemoral arteries was performed with a pigtail catheter via a 6-Fr sheath in the right brachial artery (BA) ( Fig. 3 A). A 0.035-in. hydrophilic guidewire (Radifocus Guidewire, Terumo, Tokyo, Japan) was advanced through the sheath to the left popliteal artery. Left CFA puncture was performed with an 83-mm-length needle using the 0.035-in. guidewire as a landmark ( Fig. 3 B). An 8-Fr sheath was inserted into the left CFA, through which a 0.014-in. hydrophilic guidewire (Cruise Guidewire, Asahi Intecc, Nagoya, Japan) was advanced to the right popliteal artery. Right CFA puncture was performed with an 83-mm-length needle using the 0.014-in. guidewire as a landmark ( Fig. 3 C). Two percutaneous closure devices (Perclose ProGlide, Abbott Vascular, Santa Clara, CA, USA) were prepared for the double preclose technique at the completion of the TAVI procedure. The 14-Fr expandable sheath was inserted into the right CFA, and an IABP (Xemex IABP Balloon Plus, Zeon, Tokyo, Japan) was inserted into the 8-Fr left CFA sheath. Right TF-TAVI was performed to implant a transcatheter heart valve (SAPIEN 3 26 mm, Edwards Lifesciences) successfully ( Fig. 3 D).
The TAVI delivery system and the IABP were removed with the patient stable hemodynamically. Angiography of the right iliofemoral artery showed no findings of access site-related vascular complications ( Fig. 3 E). We then proceeded to the double crossover technique. First, the femoral crossover technique was performed. A semicompliant over-the-wire balloon (Mustang Balloon 8.0 × 40 mm, Boston Scientific, Boston, MA, USA) with a 0.035-in.-diameter central lumen was advanced over the 0.014-in. guidewire through the left CFA sheath into the right EIA just proximal to the right CFA e-sheath and was subsequently inflated to a pressure of 8 atm in 3 min with manual compression at removal of the sheath ( Fig. 3 F). For the right CFA, the double preclose technique was performed with the crossover technique. By injecting contrast via the central balloon lumen with the over-the-wire balloon in the right EIA, we confirmed that there were no findings of access site-related bleeding or vascular complications ( Figs. 3 G and 4 ). Second, the brachial crossover technique was performed; the same balloon was advanced over the 0.035-in. hydrophilic guidewire through the right BA sheath into the left EIA just proximal to the left CFA sheath and was inflated to a pressure of 8 atm in 7 min with manual compression at removal of the sheath ( Fig. 3 H). The final angiography and postprocedural course showed that there was no evidence of periprocedural access site-related vascular complications. Echocardiography showed an improved left ventricular ejection fraction of 50%, a mean pressure gradient across the aortic valve of 8 mmHg, and no findings of significant paravalvular leakage. The patient restarted warfarin the next day and was discharged 10 days later following TAVI.
