eISSN: 1897-4295
ISSN: 1734-9338
Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej
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3/2012
vol. 8
 
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Case report
Is only severe vascular tortuosity a contraindication for the transfemoral approach of transcatheter aortic valve implantation?

Ahmet ÇagrI Aykan
,
Tayyar Gökdeniz
,
Mustafa Tarik Agaç
,
Șükrü Çelik

Postep Kardiol Inter 2012; 8, 3 (29): 265–268
Online publish date: 2012/09/17
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Introduction

Transcatheter aortic valve implantation (TAVI) is an alternative therapy for surgery in patients with severe symptomatic aortic stenosis at high risk for surgery. Although TAVI is less invasive it is associated with major complications including valve embolization, stroke, perforation, coronary obstruction, and atrioventricular block [1-3]. Severe vascular tortuosity was associated with major vascular complication. The transapical approach is recommended in patients with vascular tortuosity [3].

Herein we present a case of aortic stenosis successfully treated with transfemoral aortic valve implantation despite severe femoral iliac and aortic tortuosity in a patient with severe chronic obstructive pulmonary disease.

Case report

An 87-year-old female patient presented with dyspnea and rest angina. She had hypertension and severe chronic obstructive pulmonary disease. She had 4/6 systolic ejection murmur at the aortic point and wheezing on physical examination. Electrocardiography demonstrated atrial fibrillation. Transthoracic echocardiography showed severe aortic stenosis (maximum/mean gradient: 68/46 mm Hg and aortic valve area: 0.52 cm2). Coronary angiography demonstrated noncritical stenosis of the left anterior descending circumflex coronary arteries. She had high risk for aortic valve replacement surgery; logistic EuroSCORE and STS scores were 24 and 20 consecutively. She had poor respiratory capacity having contraindication for general anesthesia. Thus transcatheter aortic valve implantation was planned for the patient. Transesophageal echocardiography showed an annulus diameter of 20 mm; hence a 23 mm balloon expandable Edwards Sapien XT valve was selected. Computed tomography demonstrated grade 3 tortuosity of femoral and iliac arteries and grade 2 tortuosity of aorta with mild calcification (Figures 1 A, B). Despite severe tortuosity, easy catheter and guide wire manipulation without difficulty during coronary angiography and mild calcification of iliac arteries and aorta, the transfemoral approach was planned. A 6 F catheter was introduced into the right common femoral artery through surgical cutdown. A 6 F Judkins right coronary catheter was introduced to the ascending aorta through a 0.038 guidewire. The 0.038 guidewire was exchanged with a 0.035 Back-up Meier guidewire which straightened the iliac tortuosity (Figure 1 C). Then the 16 F Edwards Sapien E-sheath was introduced. A transient pacemaker was implanted in the right ventricular apex through the narrowed and tortuous left iliac vein from the left femoral vein (Figure 1 D). Aortic balloon valvuloplasty was performed (Figure 2 A). The 23 mm Edwards Sapien XT bioprosthetic valve catheter was advanced gently over the guide and lightly flexed in the tortuous descending aorta and further flexed in the aortic arch while the guidewire was detensioned by slightly pulling the guidewire. The aortic arch was crossed with the fully flexed catheter and the valve was located at the proper position and successfully implanted (Figures 2 B, C). Final aortography showed trivial aortic regurgitation. The catheter was removed without any complications (Figure 2 D). The patient was discharged uneventfully.

Discussion

Vascular complications that significantly increase patient morbidity and mortality are common in transfemoral TAVI [3-5]. Thus severe iliofemoral tortuosities, severe calcification, porcelain aorta, significant atheroma of the femoral and iliac vessels constitute contraindications for transfemoral TAVI [3]. Vessel tortuosity was evaluated as according to the tortuosity score which was defined as: 0 no tortuosity; 1 mild tortuosity (30° to 60°); 2 moderate tortuosity (60° to 90°); and 3 marked tortuosity (> 90°). Despite the marked tortuosity of the iliac and femoral arteries and moderate tortuosity of the descending aorta, we easily performed the coronary angiography. Furthermore the calcification grade is more important in the development of vascular complications, which was mild in this patient [2]. For advancing the valve a stiff wire is needed. The backup Meier, Lunderquist and Amplatz extra stiff wires are generally preferred. We used the backup Meier guidewire which totally straightened the tortuous iliac and femoral arteries and partially flattened the descending aorta. During advancement of the E-sheath we did not feel resistance. The guidewire should stay in the left ventricle during the procedure and advancing a valve catheter in a tortuous aorta may displace the guidewire; thus the guide wire should be detensioned by gently pulling back the catheter while advancing the valve over tortuous and angled areas. With increasing age the vascular tortuosity increases, and aortic stenosis is common among elderly patients. Thus patients with aortic stenosis may have varying degrees of vascular tortuosity. Calcium deposition is associated with rigidity of the vessels and an insult to the severely calcified vessel may cause perforation and rupture of the vessel. Furthermore, a heavily calcified vessel loses its elasticity.

In conclusion, vascular calcification may be more important than tortuosity and transfemoral TAVI may be performed in severely tortuous vessels successfully by an experienced interventional cardiologist.

References

 1. Dagdelen S, Karabulut H, Alhan C. Acute left main coronary artery occlusion following TAVI and emergency solution. Anadolu Kardiyol Derg 2011; 11: 747-748.

 2. Hayashida K, Lefe`vre T, Chevalier B, et al. Transfemoral aortic valve implantation new criteria to predict vascular complications. JACC Cardiovasc Interv 2011; 4: 851-858.

 3. Holmes DR Jr, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2012; 59: 1200-1254.

 4. Rodés-Cabau J, Webb JG, Cheung A, et al. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010; 55: 1080-1090.

 5. Webb JG, Chandavimol M, Thompson CR, et al. Percutaneous aortic valve implantation retrograde from the femoral artery. Circulation 2006; 113: 842-850.
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