Simultaneous transfemoral valve-in-valve transcatheter aortic valve replacement and debranching thoracic endovascular aortic repair through a tortuous and shaggy aorta: a case report

A successful transfemoral transcatheter aortic valve replacement case with VIABAHN® VBX balloon-expandable stent-graft and long Dryseal sheath for challenging access route

Key Clinical Message

A combination of long large-bore sheath and balloon-expandable stent-graft can be effective to challenging access route in transfemoral transcatheter aortic valve replacement.

Abstract

An 88-year-old female with symptomatic severe aortic stenosis underwent transcatheter aortic valve replacement (TAVR). Multidetector computed tomography demonstrated a small aortic annulus, shaggy aorta, and significant stenosis with heavily calcified atherosclerotic lesions in the bilateral common iliac arteries (CIAs). TAVR with Evolut™ Pro+ via alternative approach was considered; however, our heart team concluded that the patient was unsuitable for the procedure due to anatomical reasons, patient frailty, and medication history. Finally, transfemoral TAVR with endovascular therapy (EVT) and 18Fr-65 cm-Dryseal was adopted for the site. Following EVT with VIABAHN® VBX balloon-expandable stent-graft (VBX) implantation to the right ostial CIA lesion, 18Fr-65 cm-Dryseal was advanced to the ascending aorta through VBX, and Evolut™ Pro+26 mm was successfully implanted without any complication. At the 2-month follow-up, the patient reported a significant improvement in shortness of breath and did not present any evidence of atheroembolism. Transfemoral TAVR with 18Fr-65 cm-Dryseal to shaggy aorta can be feasible depending on the plaque distribution, and VBX implantation to a heavily calcified ostial CIA lesion was safe and effective for obtaining enough lumen for a large-bore sheath.

Anesthetic Considerations in Endovascular Repair of the Ascending Aorta

Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.