TAVI: The way in, where there is no other way
Consult this Twitter case concerning a patient with severely diseased aorta, and no options for transvascular or transapical approach who underwent self-expandable TAVI through sheathless transcaval approach
This case was originally published on Twitter by @ignamatsant via #CardioTwitterCase
Clinical presentation
This is the case of a 73-year-old man who presented with heart failure due to severe aortic stenosis. He also had moderate chronic obstructive pulmonary disease and a EuroSCORE-II of 27%. Due to porcelain aorta (in fact complex atherosclerotic plaques in all the aorta and mainly in the ascending segment) initially transapical TAVI was considered since femoral and axillary accesses were non-feasible. However, anatomical conditions (the apex was far from the thoracic wall) led to select transcaval approach for the TAVI procedure.
Case Management
Through right femoral vein, a mammary catheter was placed facing the abdominal aorta and a snare from left femoral artery was opened within descending aorta and in front of the mammary catheter (verified in 2 orthogonal projections).
An Astato wire (Asahi) whose distal edge has been previously burnished with the scalpel and then kept together with an electric scalpel with a clamp, was pushed from the inferior vena cava to the snare in the aorta while electrified. Once it crossed the closer wall of the aorta, it was captured by the snare and pulled up. The wire was within a Finecross microcatheter (Terumo) that was also within a Navicross catheter (Terumo).
In order to advance the Navicross, it was required to predilate the aorta’s wall with a 2 mm balloon. Once the Navicross was advanced, the Astato wire was exchanged by a Lunderquist extrasupport wire. An AL1 catheter was advanced up to the ascending aorta, the stenotic aortic valve was crossed with a straight teflon wire and once in the left ventricle, it was exchanged by the preformed Lunderquist wire.
Then, a 34-mm Evolut-R TAVI device was advanced and implanted successfully with moderate leak; therefore, the delivery system was removed and an 8.5 Fr Agilis steerable sheath (Abbott Vascular) was advanced from the cava into the aorta, a 25-mm balloon was used for post-dilation without any residual paravalvular leak and, afterwards, a ductus occluder device 10/5 mm (Abbott Vascular) was successfully implanted with no residual contrast leak from the aorta.
Original tweet and Twitter discussion
SHEATHLESS transcaval TAVR.
— Ignacio J. Amat (@ignamatsant) February 21, 2020
No, the long femoral sheath is not compulsory.
No, we are not crazy.
Successful Evolut R implanted today in HCU Valladolid @TAVRBot@PCRonline@MedtronicESpic.twitter.com/JOAWYKEjMO
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