Porcelain aorta, calcified aortic valve, and calcified left main: what comes first, the valve or the artery?

Valve or artery first?

Clinical presentation

• 76-year-old male patient
• Absolutely “fit”
• Severe AS symptomatic for angina (CCS class-II and worsening to class-III + NYHA class II in the last 6 months)
• LV function (EF 55 %), renal GFR (50 ml/min)
• Sinus rhythm with RBBB (with risk of total AV-block)
• Previous bilateral CEA
• Doppler: total occlusion of the left CCA, and total occlusion of the subclavian (and vertebral left artery)

CT scan

Porcelain aorta and occluded left common carotid artery

Porcelain aorta and occluded left common carotid artery

Occluded subclavian artery

Occluded subclavian artery

Calcified LVOT

Calcified LVOT

Valve sizing and LM calcification

LVOT

LVOT

RCA

RCA

STJ

STJ

Massive calcification of the LM and LAD/LCx

Massive calcification of the LM and LAD/LCx

LCA

LCA

Calcified aorta and iliacs

Calcified aorta and iliacs

Common femoral arteries

Common femoral arteries

Coronary angiogram

Severe disease of the anonymous trunk and occlusion of a minor RCA

Heart Team meeting

Despite the "youngish" aspect of the patient, and the “low” surgical risk, SAVR + CABG x 3 in a man with porcelain aorta and occlusion of 2/4 epi-aortic vessels was considered to have an unfavourable risk balance, compared to combined TAVI + PCI endovascular approach.

However, different endovascular teams would plan this case differently…

Tell us how would you manage this case!