Successful Use Of A Balloon-Expandable And Recollapsible Sheath In Transcatheter Aortic Valve Replacement With Prior Endovascular Aortic Repair With Endologix Stent Graft
Anoshia Raza, MD1, Syed Zaid, MD1, Hasan Ahmad, MD2, Cenap Undemir, MD1,
Martin Cohen, MD2, Steven L. Lansman, MD, PhD1, Gilbert H. L. Tang, MD, MSc, MBA1.
1Section of Cardiothoracic Surgery, 2Division of Cardiology, Westchester Medical Center, Valhalla, NY, USA.
PATIENT DEMOGRAPHICS & RELEVANT HISTORY
Patient is a 75 year old frail female with Past Medical History that includes
- NYHA-III diastolic heart failure
- Porcelain aorta from prior chest irradiation from malignancy complicated by left arm lymphedema
- Moderate coronary artery disease
- Stage-IV chronic kidney disease.
- Prior EVAR for AAA with an Endologix endograft, complicated by endoleak requiring Palmaz stent.
Patient was diagnosed with symptomatic severe aortic stenosis and deemed inoperable for open surgery. Given comorbidities and frailty, transfemoral TAVR was her only option.
CT showed aortic annular dimensions 26.6 x 22.0 mm, area 457 mm2 and perimeter 76.5 mm, with severe annular and LVOT calcification. A 29mm-CoreValve was selected.
CHALLENGES TO OUR CASE
Transfemoral CoreValve TAVR combined with EVAR had been reported once but TAVR preceded EVAR. Our case proves challenging for two reasons.
- Rigid endoskeleton design (metal frame within the fabric) of the Endologix graft overlapped by a Palmaz stent could risk catheter trapping between two prostheses. Advancing large-bore introducer sheath in such rigid aortoiliac anatomy could risk contact with the metal frame of the Endologix graft and the Palmaz stent, risking migration and dislodgement of the vascular prostheses and catastrophic complication.
- Introducer sheath must be long enough for its tip to be positioned proximal to the Palmaz stent in the native aorta to avoid advancing the valve delivery catheter through the stented portion of the aorta.
To our knowledge, 11/19-French balloon-expandable, recollapsible Terumo Solopath sheath has been used in TAVR with CoreValve in small and tortuous iliofemoral access but not through an Endologix endograft.
35-cm-long 11/19-French balloon-expandable, recollapsible (BERC) Solopath sheath with its smaller insertion profile, flexibility and longer length enabled safe insertion past the Endologix endograft with its tip positioned just proximal to the Palmaz stent (Figure A)
A 29 mm CoreValve was successfully delivered and implanted using standard techniques with only 40 mL of IV contrast, under conscious sedation and transthoracic echocardiography monitoring (Figure B and C)
Completion abdominal aortic angiogram showed no migration of her prior Endologix and Palmaz prostheses and no evidence of endoleak (Figure D)
Patient had prior RBBB and LAFB and developed complete heart block during stiff guidewire placement in the left ventricle requiring a permanent pacemaker after valve implantation but otherwise was discharged home uneventfully in 2 days.
TTE at 30 days showed mild paravalvular aortic regurgitation due to her severe LVOT calcification, but excellent hemodynamics with mean gradient 2 mmHg, peak gradient 4 mmHg and prosthetic valve area 2.53 cm2.
The smaller insertion profile, flexibility and longer length of the Solopath sheath enabled us to safely advance the CoreValve delivery system beyond stented portion of the abdominal aorta and allowed successful valve implantation, and delivery system and sheath removal. The BERC sheath therefore provides an additional option for transfemoral TAVR in patients with prior EVAR and high risk aortic root anatomy, cases where a self-expanding valve would be preferred over a balloon-expandable prosthesis.