Abstract
Transcatheter aortic valve implantation (TAVI) has nowadays been introduced as an alternative for surgical aortic valve replacement as a treatment for high risk aortic stenosis patients. This procedure is not free of complications: the SOURCE registry, indeed, showed that vascular complications are more frequent with the transfemoral approach. We present the case of an 82-year-old man with known history of severe aortic stenosis at high-risk for surgery. Pre-TAVI screening shows bilateral severely tortuous iliac arteries and aorto-bi-iliac endoprosthesis. Transapical TAVI as a first choice was rejected due to severe lung disease. The patient was then treated by Transfemoral TAVI using a dedicated interventional technique that is described in this case-report.
1
Introduction
Transcatheter aortic valve implantation (TAVI) was introduced as an alternative for surgical aortic valve replacement (SAVR) as treatment for high surgical risk aortic stenosis patients. The PARTNER US Trial (Cohort B) has demonstrated its superiority over medical treatment in patients unsuitable for aortic valve surgery . According to the SOURCE Registry vascular complications are more frequent with the transfemoral approach than with the transapical (11.3% Vs 2%, P < .0001), and their relevant clinical impact should encourage careful patient selection . Clinical, anatomic and functional characteristics impact procedural outcomes and have to be considered when evaluating potential candidates. Vessel minimal luminal diameter, tortuosity and calcification of the aorta, iliac and femoral arteries must be assessed and should influence patient selection and implantation route. In patients with small, heavily calcified, tortuous arteries a transapical approach should be preferred in order to prevent serious vascular complications. However, vessel tortuosity itself should not be considered as an absolute contraindication for the transfemoral approach as long as the arteries straighten after the insertion of a stiff guide wire . The presence of an aorto-iliac endoprosthesis in patients with severe vascular disease represents a further challenge to transfemoral TAVI that, to our knowledge, has not been previously reported as a real case.
The transapical route should be preferred in the presence of a complicated anatomy, but it also presents some limitations in patients with chest wall deformity, severe lung disease, chest wall trauma or infection, severely depressed left ventricular function and previous cardiac surgery. Accordingly, other alternative access sites have been reported, such as trans-axillary, or direct trans-aortic approaches.
2
Case report
An 82-year-old male with severe aortic valve stenosis was admitted as an emergency with repeated episodes of syncope and overt heart failure. He was rejected for SAVR in view of a severe pulmonary disease with bilateral emphysematous lungs (GOLD classification stage III), left anterior descending coronary artery disease and chronic kidney disease (Euroscore 32.82). After reviewing ilio-femoral axis diameter [ Fig. 1 A & B] Heart Team opted for a trans-femoral approach because of the severe lung disease despite the presence of an aorto-bi-iliac endoprosthesis with severe tortuosity of the ilio-femoral axes, determining an approximately 360° loop on the right external iliac artery and a 260° loop on the left side, respectively [ Fig. 2 A & B]. The diameter of ilio-femoral axis was adequate.
Trans-catheter aortic valve implantation (TAVI) was then undertaken with surgical exposure of left femoral artery. As usual, an extra-stiff wire was inserted upwards through the common femoral artery to straighten the left iliac tortuosity. The 22F introducer however, could not be completely advanced beyond the endoprosthetic part of the left common iliac, and after several attempts it was removed revealing damage located at its tip, likely due to the friction against the vascular calcium and the struts of the endoprosthesis. A second extra-stiff wire was therefore advanced from the right brachial artery to the left superficial femoral artery through a multipurpose catheter for additional support [ Fig. 3 A ]. A new 22F introducer was finally advanced with success as a “railing track” and the second wire was then removed. After conventional balloon valvuloplasty, a 23 mm Edward-Sapien XT aortic valve was successfully implanted [ Fig. 3 A]. Intra-operative trans-oesophageal echocardiography showed trivial para-prosthetic leak [ Fig. 3 B]. The femoral access was surgically repaired without complications [ Fig. 3 B] and the patient was discharged uneventfully on postoperative day 10. To our knowledge he is doing well three months after the procedure.
