A Unique Complication of Transcatheter Aortic Valve Replacement (TAVR) in the Setting of Abdominal Aortic Aneurysm Requiring Bailout by Entrapment with Endovascular Repair
Presenter
Balaj Rai, MD, Kettering Health Network, Dayton, OH
Balaj Rai, MD1, Abdur Rehman, MD2, Damian N. Valencia, MD3, Marvin Amen1, Prasanth Lingam, MD3, Joshua Ahier, MD3 and Brian Schwartz, MD, FSCAI4, (1)Kettering Health Network, Dayton, OH, (2)Kettering Health Network, Beavercreek, OH, (3)Kettering Health Network, Kettering, OH, (4)Kettering Health Network, Springboro, OH
Keywords: Abdominal Aortic Aneurysm (AAA), Complications and TAVI/TAVR/Aortic Valve
Background
:
Surgical bailout is still required in approximately 1.17% of TAVR and 30-day and 1-year incidence of MACE and all-cause mortality were significantly higher in the STS/ACC TVT Registry. We present a novel non-surgical bailout technique in a very high-risk patient by successfully trapping an aborted TAVR valve into an aneurysmal sac with an emergent three–piece endovascular aneurysm repair of an infrarenal AAA without complications. Methods
:
A 77-year-old male with PMHx of PAF, dual chamber PPM, and 5.6 cm x 5.1 cm fusiform bilobed infrarenal AAA presented with severe, symptomatic NYHA class III, stage D1 aortic stenosis. TTE showed Vmax 4.70 m/s, MG 48 mmHg, AVA 0.57 cm², DI 0.16, and LVEF 60%. Patent was evaluated by the structural heart team and deemed high risk for SAVR. Given the excessive angulation of the aorta ~ 90˚ at the aortic hiatus, a 29mm Edwards Sapien S3 Ultra valve was selected. Results
:
The right groin sheath was successively dilated to a 14F expandable sheath which was advanced above the AAA, over an Amplatz super-stiff wire, followed by the Sapien valve. It was difficult to track the valve up to the descending thoracic aorta. Upon trying to maneuver the valve delivery system, the sheath split, and the delivery system protruded from the sidewall and coiled on itself in the aneurysm sac. This put substantial force on the aneurysm and made it impossible to advance or withdraw the Sapien valve. The TAVR delivery system was left in place, and the 14F sheath was peeled away. The left femoral sheath was upsized. A Kumpe catheter was passed through the aneurysm, bringing a three-piece Gore endograft inferior to the renal arteries. A peripheral balloon was used to guide the valve behind the endograft. The graft, limbs, distal, and proximal landing zones were ballooned. The patient was discharged home on postoperative day three
with plans to complete TAVR using carotid approach. Conclusions
:
If EVAR was performed first, recovery from the cariogenic shock may have been difficult given the severe AS and, and a dysfunctional valve may not tolerate the balloon occlusion and cardioplegia required for surgical bailout. In retrospect, we could have used a longer sheath to cross the AAA, thus providing more stability and lowering the risk of rupture.