A unique approach for patients with severe aortoiliac disease requiring high risk coronary and structural heart interventions
Presenter
Inderjeet Bharaj, MD, Abrazo Health, Glendale, AZ
Inderjeet Bharaj, MD1, Ei Ei Thwe, MD2, Samer Ibrahim, MD2, Ravi Inder Mann, M.D.3 and Merick Kirshner, MD2, (1)Abrazo Health, Glendale, AZ, (2)Abrazo Arizona Heart Hospital, Phoenix, AZ, (3)Abrazo Arrowhead Hospital, Glendale, AZ
Title
A unique approach for patients with severe aortoiliac disease requiring high risk coronary and structural heart interventions
Introduction
Aortic calcification is associated with an increased risk of major adverse cardiovascular events. Managing heavily calcified aortic lesions in the context of necessitating a large-diameter sheath for a high risk percutaneous intervention can be challenging. Various plaque modification approaches have been proposed. This case illustrates a novel technique for managing severe descending aortic calcification using intravascular lithotripsy (IVL). Clinical Case
An 81 year-old male with past medical history of CAD (prior PCI) and hypertension presented to the ED after a syncopal episode. He reported recurrent sudden episodes without prodromal symptoms resulting in falls. Echocardiogram showed hyperdynamic LV function, probably trileaflet, thickened, and calcified aortic valve leaflets with severe aortic stenosis (peak/mean gradient 83/43 mmHg, AVA of 0.9 cm2) and mild-moderate AR. Patient underwent left heart catheterization that showed severe left main disease confirmed by IVUS and iFR. Additionally resistance was noted to J-wire through the abdominal aorta. Abdominal aortogram with bilateral iliac runoffs demonstrated stenosis around the origin of the renal arteries which would make large bore sheath placement difficult. Multidisciplinary team discussion was done, the patient was deemed not to be a surgical candidate. Decision was made to proceed with high risk Impella assisted PCI after intervention from Vascular surgery for the abdominal aortic stenosis and staged TAVR. CT Aortogram confirmed the abdominal aortic calcification between the SMA and the right renal artery. Two Shockwave M5 7x60 mm catheters, one from each groin were advanced into the aorta at the site of stenosis. Balloon angioplasty of the aorta was performed by intravascular lithotripsy (IVL) and simultaneously performing angioplasty. Repeat angiogram showed residual stenosis of about 40% from 90% but the lumen had significantly improved. Next, Impella assisted left main intervention s/p PCI with DES from left main to LAD and left main to circumflex was done in the same session. The patient underwent TAVR with implantation of Edwards SAPIEN 26 mm S3 valve after 3 weeks. No resistance to flow was noted after sheath placement, confirmed in bilateral femoral arteries during the procedure. After 6 months follow up, the patient remained stable from a cardiovascular standpoint. Discussion
IVL is an intuitive and attractive modality for the treatment of severely calcified lesions that combines the calcium-disrupting capability of lithotripsy with the familiarity of balloon catheters. Clinical studies to date support the effectiveness of IVL in inducing circumferential fracture in calcific plaques, leading to significant luminal gain. In patients with inadequate iliofemoral vascular access alternative approaches have been trialed. However, early experience with transapical approach in TAVR suggested a trend toward less favorable periprocedural outcomes and a steep learning curve. Transaortic could be challenging in patients with heavily calcified aortas, previous sternotomies, or redo cardiac surgery. Shockwave lithotripsy for aortic calcification could be considered as an alternative approach for severe aortic stenosis to aid high risk PCI and TAVR if options are limited.