A Completely Endovascular Solution for Transcatheter Aortic Valve Implantation Embolisation and Inversion into the Aortic Arch

Abstract

Introduction: Transcatheter aortic valve implantation (TAVI) has evolved into the preferred alternative to surgical valve replacement for severe aortic valve stenosis with high surgical risk. With expanding indications, life threatening complications including transcatheter aortic valve embolisation and inversion (TAVEI), in which the valve dislodges, inverts, and migrates caudally, may increase concomitantly.

Report: An 80 year old male with severe aortic valve stenosis underwent balloon expandable transcatheter aortic valve implantation (TAVI). Valve embolisation into the aortic arch inverted the bioprothesis, excluding the option of fixation in the descending aorta. Through-valve thoracic endovascular aortic repair (TEVAR) was performed after bifemoral snaring using a through-and-through wire technique and pulling the valve into the descending aorta.

Discussion: TAVI is emerging as the preferred treatment for severe aortic valve stenosis and comes with unique procedural complications, such as life threatening transcatheter aortic valve embolisation and inversion (TAVEI). Although some authors prefer treating embolisation of a non-inverted balloon expandable valve into the aorta by using the valvuloplasty balloon to pull the valve distally and fixing it in the descending aorta, this risks further expansion of the valve and consequently fixing it in an undesirable position and is not possible if the valve inverts. Downstream placement of the valve by snaring with a guiding catheter covering/protecting a through-and-through wire technique, combined with through-valve TEVAR, provides a new bail out strategy for this serious complication and may reduce TAVEI associated mortality and morbidity.

Keywords: Aortic (valve) stenosis; Embolisation; Endovascular; TAVI; Thoracic stent graft.

Figure 1

Intra-operative fluoroscopy. (A) Following failed capture of the temporary pacemaker and lost guidewire position through the valve, the 26 mm Edwards SAPIEN 3 Ultra aortic bioprosthesis migrates to the ascending aorta. (B) The embolised valve inverts and migrates further into the aortic arch at the left common carotid artery origin. (C) Compromised, but flow present past the embolised valve. A femoro-femoral through-and-through wire set up was established using two 7 F Check-Flo® introducer sheaths guided over two 260 cm 0.035″ Radiofocus® guidewires and pushing a dilatator into the other. Manual traction pulled the bioprosthesis 3 cm caudally into the descending aorta, distal of the left LSA origin. (D) Fluoroscopy via the left brachial artery, showing successful in-valve thoracic endovascular aortic repair (Valiant™ Captiva™), fixing the embolised and inverted bioprosthesis distal to the left subclavian artery (LSA) origin with sufficient flow to the brachiocephalic artery (I), left common carotid artery (II), and LSA (III) (further filling of the LSA was shown on subsequent fluoroscopy frames).

Figure 2

Post-operative computed tomography scan (I) and volume rendered reconstruction (II). Successful in valve thoracic endovascular aortic repair (Valiant™ Captiva™) (A), fixing the dislodged and inverted bioprosthesis distal of the left subclavian artery (LSA) origin (B). Although part of the LSA was overstented, intra-operative fluoroscopy showed sufficient flow to it. A second, functional 26 mm Edwards SAPIEN 3 Ultra aortic bioprosthesis is positioned in the aortic annulus (C).