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A “double crossover technique” in an obese patient undergoing transfemoral transcatheter aortic valve implantation: How to accomplish hemostasis percutaneously?
Cardiovascular Revascularization Medicine 18 (2017) 440–444
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Case Reports
A “double crossover technique” in an obese patient undergoing transfemoral transcatheter aortic valve implantation: How to accomplish hemostasis percutaneously? Hirokazu Onishi, Toru Naganuma, Sunao Nakamura ⁎ Department of Cardiology, New Tokyo Hospital, Chiba, Japan
a r t i c l e
i n f o
Article history: Received 28 February 2017 Received in revised form 22 March 2017 Accepted 29 March 2017 Keywords: Crossover technique Obesity Transcatheter aortic valve implantation Intra-aortic balloon pump
a b s t r a c t Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure but may be associated with vascular complications at femoral access sites, particularly in obese patients. This report aimed to describe a case of successful performance of our “double crossover technique” in an obese patient undergoing TF-TAVI with a percutaneous transfemoral intra-aortic balloon pump (TF-IABP). A 75-yearold man presented with heart failure due to a left ventricular ejection fraction of 35% and low-flow, lowgradient severe aortic stenosis. The logistic EuroSCORE and STS-PROM score were 31.38% and 7.311%, respectively. Right TF-TAVI using a 14-Fr expandable sheath and a left TF-IABP using an 8-Fr sheath were scheduled. The patient was obese, with a body mass index of 31.7 kg/m2, and we expected access site-related vascular complications to occur. Subsequently, we performed a femoral and brachial crossover technique, called the “double crossover technique,” at the completion of the TAVI procedure: first, for the right common femoral artery (CFA) through the sheath in the left CFA and second, for the left CFA through the sheath in the right brachial artery. In the crossover technique, an 8.0-mm-diameter over-the-wire balloon was advanced to an external iliac artery and was subsequently inflated when the sheath was removed. For the right CFA, a double preclose technique was used with the crossover technique. There was no evidence of access site-related vascular complications following TAVI. The double crossover technique was effective at achieving hemostasis and avoiding access site-related vascular complications in an obese patient undergoing TF-TAVI with a TF-IABP. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure in patients at intermediate and high surgical risk [1–4]. However, access site-related major vascular complications in TF-TAVI, defined according to the Valve Academic Research Consortium-2 criteria, are not rare and are associated with increased morbidity and mortality [5,6]. When TAVI is performed in patients with left ventricular systolic dysfunction, the use of mechanical circulatory support devices during TAVI, such as a percutaneous transfemoral intra-aortic balloon pump (TF-IABP) and an extracorporeal membrane oxygenation device, is considered helpful [7]. Access site-related vascular complications are expected to be frequent in obese patients undergoing TF-TAVI with mechanical circulatory support devices. The femoral crossover technique and radial crossover technique are successful and useful methods
Abbreviations: TF-TAVI, transfemoral transcatheter aortic valve implantation; TF-IABP, transfemoral intra-aortic balloon pump. ⁎ Corresponding author at: New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 2702232, Japan. Tel.: +81 47 366 7000; fax: +81 47 392 8718. E-mail address: [email protected] (S. Nakamura). http://dx.doi.org/10.1016/j.carrev.2017.03.030 1553-8389/© 2017 Elsevier Inc. All rights reserved.
of accomplishing hemostasis and avoiding access site-related vascular complications following TAVI [8–11]. This report aimed to describe a case of successful femoral and brachial crossover technique, called the “double crossover technique,” in an obese patient undergoing TF-TAVI with a TF-IABP. 2. Case A 75-year-old man presented with worsening chronic heart failure due to low-flow, low-gradient severe aortic stenosis and was admitted to our hospital. Echocardiography revealed a left ventricular ejection fraction of 35%, an aortic valve area of 0.73 cm2, a mean pressure gradient across the aortic valve of 31 mmHg, and no significant aortic regurgitation. The patient had some comorbidities: paroxysmal atrial fibrillation, non-insulin-dependent diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease. There were no findings of ischemic heart disease. The logistic EuroSCORE and the STSPROM score were 31.38% and 7.311%, respectively. According to contrast-enhanced computed tomography, there was no contraindication in the bilateral femoral access routes for TF-TAVI (Fig. 1). The minimum lumen diameters of the right external iliac artery (EIA) and the right common femoral artery (CFA) were 7.1 and 5.8 mm,
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procedure. The 14-Fr expandable sheath was inserted into the right CFA, and an IABP (Xemex IABP Balloon Plus, Zeon, Tokyo, Japan) was inserted into the 8-Fr left CFA sheath. Right TF-TAVI was performed to implant a transcatheter heart valve (SAPIEN 3 26 mm, Edwards Lifesciences) successfully (Fig. 3D). The TAVI delivery system and the IABP were removed with the patient stable hemodynamically. Angiography of the right iliofemoral artery showed no findings of access site-related vascular complications (Fig. 3E). We then proceeded to the double crossover technique. First, the femoral crossover technique was performed. A semicompliant overthe-wire balloon (Mustang Balloon 8.0 × 40 mm, Boston Scientific, Boston, MA, USA) with a 0.035-in.-diameter central lumen was advanced over the 0.014-in. guidewire through the left CFA sheath into the right EIA just proximal to the right CFA e-sheath and was subsequently inflated to a pressure of 8 atm in 3 min with manual compression at removal of the sheath (Fig. 3F). For the right CFA, the double preclose technique was performed with the crossover technique. By injecting contrast via the central balloon lumen with the over-the-wire balloon in the right EIA, we confirmed that there were no findings of access site-related bleeding or vascular complications (Figs. 3G and 4). Second, the brachial crossover technique was performed; the same balloon was advanced over the 0.035-in. hydrophilic guidewire through the right BA sheath into the left EIA just proximal to the left CFA sheath and was inflated to a pressure of 8 atm in 7 min with manual compression at removal of the sheath (Fig. 3H). The final angiography and postprocedural course showed that there was no evidence of periprocedural access site-related vascular complications. Echocardiography showed an improved left ventricular ejection fraction of 50%, a mean pressure gradient across the aortic valve of 8 mmHg, and no findings of significant paravalvular leakage. The patient restarted warfarin the next day and was discharged 10 days later following TAVI. 3. Discussion Fig. 1. Three-dimensional computed tomographic angiography of the aorta to the bilateral iliofemoral arteries.
respectively. Right TF-TAVI using a 14-Fr expandable sheath (e-Sheath, Edwards Lifesciences, Irvine, CA, USA) was scheduled with a preprocedural left TF-IABP using an 8-Fr sheath because of left ventricular systolic dysfunction. The patient gave informed consent for the procedure before it began. The patient received antithrombotic therapy with aspirin 100 mg/ day and warfarin. Warfarin was stopped and heparinization was started 3 days before TAVI. Heparinization was stopped 6 h before starting TAVI. The patient was 173 cm tall and weighed 95 kg, with a body mass index of 31.7 kg/m 2, indicating obesity. As shown by computed tomography, the estimated distance between the skin and the right CFA puncture was at least 70 mm (Fig. 2). We expected that vascular complications at the femoral access sites could occur. Therefore, we performed TFTAVI using the “double crossover technique” in the following manner, with the patient under general anesthesia (Fig. 3). Angiography of the aorta to the bilateral iliofemoral arteries was performed with a pigtail catheter via a 6-Fr sheath in the right brachial artery (BA) (Fig. 3A). A 0.035-in. hydrophilic guidewire (Radifocus Guidewire, Terumo, Tokyo, Japan) was advanced through the sheath to the left popliteal artery. Left CFA puncture was performed with an 83-mm-length needle using the 0.035-in. guidewire as a landmark (Fig. 3B). An 8-Fr sheath was inserted into the left CFA, through which a 0.014-in. hydrophilic guidewire (Cruise Guidewire, Asahi Intecc, Nagoya, Japan) was advanced to the right popliteal artery. Right CFA puncture was performed with an 83-mm-length needle using the 0.014-in. guidewire as a landmark (Fig. 3C). Two percutaneous closure devices (Perclose ProGlide, Abbott Vascular, Santa Clara, CA, USA) were prepared for the double preclose technique at the completion of the TAVI
In obese patients undergoing coronary angiography or percutaneous coronary intervention, access site-related bleeding and vascular complications are reportedly more frequent with the transfemoral approach than with the transradial approach [12]. These complications are expected to be frequent in obese patients undergoing TF-TAVI with transfemoral mechanical circulatory support devices that are helpful for patients with left ventricular systolic dysfunction [7]. In the present obese patient undergoing TF-TAVI with a TF-IABP, we performed the double crossover technique with the double preclose technique. There are three main advantages of the crossover technique: 1) secure CFA puncture with a guidewire across the CFA as a landmark, 2) successful hemostasis with balloon inflation at femoral access sites, and 3) instant detection and subsequent treatment for access siterelated vascular complications with an over-the-wire balloon. 1) Secure CFA puncture with a guidewire across the CFA as a landmark. In the present case, computed tomography showed that the estimated distance between the skin and the site of the right CFA puncture with a needle was at least 70 mm (Fig. 2). Therefore, at the start of the TF-TAVI procedure, we needed an 83-mmlength needle to puncture the CFA. By using a guidewire across the CFA as a landmark, we achieved CFA puncture securely to avoid access site-related vascular complications [8,10]. 2) Successful hemostasis with balloon inflation at femoral access sites. In the crossover technique after transcatheter heart valve implantation, an over-the-wire balloon over a guidewire across a CFA is advanced into the ipsilateral EIA just proximal to the CFA sheath. At removal of the CFA sheath, the balloon is inflated at the ipsilateral EIA with manual compression for hemostasis of the femoral access site. The femoral crossover technique has a
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Fig. 2. (A, B) Axial computed tomographic images of the abdominal area. (C) Sagittal computed tomographic image of the abdominal area. The red dotted lines indicate the levels of panels A and B. The blue dotted line indicates the estimated distance between the skin and the site where the right common femoral artery was punctured with a needle.
high procedural success rate and reduces the rates of access siterelated bleeding and major vascular complications, leading to decreased mortality following TAVI [9]. Furthermore, the radial crossover technique is a reasonable alternative to the femoral crossover technique [11]. It is considered useful for patients in whom the contralateral femoral artery is anatomically unfavorable or is already in use. 3) Instant detection and subsequent treatment for access siterelated vascular complications with an over-the-wire balloon. There is a residual space at a 0.035-in.-diameter central balloon lumen of an over-the-wire balloon over a 0.014-in. guidewire across an iliofemoral artery. This space enables low-dose contrast to be injected with the guidewire left in the true lumen of the iliofemoral artery and without retraction of the balloon. Therefore, the crossover technique is also useful for enabling instant detection and subsequent treatment of access site-related vascular complications at the completion of the TF-TAVI procedure.
3.1. The double preclose technique in addition to the crossover technique in obese patients The rate of access site-related vascular complications is not significantly different between patients undergoing the double and single preclose techniques [13]. However, the study mainly included patients with normal body mass indexes. For obese patients undergoing TFTAVI, the double preclose technique may be helpful in case of single preclose failure. It is expected that hematoma of the femoral access sites may not be detected instantly and that adequate manual compression may be difficult to perform in obese patients.
4. Conclusion The double crossover technique was effective at achieving hemostasis and avoiding access site-related vascular complications of the puncture site in an obese patient undergoing TF-TAVI with a TF-IABP. References [1] Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. (1533-4406 (Electronic)). [2] Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374(17):1609–20. [3] Biancari F, Rosato S, D'Errigo P, Ranucci M, Onorati F, Barbanti M, et al. Immediate and intermediate outcome after transapical versus transfemoral transcatheter aortic valve replacement. Am J Cardiol 2016;117(2):245–51. [4] Frohlich GM, Baxter PD, Malkin CJ, Scott DJ, Moat NE, Hildick-Smith D, et al. Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry). Am J Cardiol 2015;116(10):1555–9. [5] Genereux P, Webb JG, Svensson LG, Svensson LG, Kodali SK, Kodali SK, Satler LF, Satler LF, Fearon WF, Fearon WF, Davidson CJ, Davidson CJ, Eisenhauer AC, Eisenhauer AC, Makkar RR, Makkar RR, Bergman GW, Bergman GW, Babaliaros V, et al. Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial. (1558-3597 (Electronic)). [6] Kappetein AP, Head SJ, Genereux P, Piazza N, van Mieghem NM, Blackstone EH, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. J Thorac Cardiovasc Surg 2013;145(1):6–23. [7] Singh V, Damluji AA, Mendirichaga R, Alfonso CE, Martinez CA, Williams D, et al. Elective or emergency use of mechanical circulatory support devices during transcatheter aortic valve replacement. J Interv Cardiol 2016;29(5):513–22. [8] Sharp AS, Michev I, Maisano F, Taramasso M, Godino C, Latib A, et al. A new technique for vascular access management in transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2010;75(5):784–93. [9] Zaman S, Gooley R, Cheng V, McCormick L, Meredith IT. Impact of routine crossover balloon occlusion technique on access-related vascular complications following transfemoral transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2016;88(2):276–84.
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Fig. 3. Double crossover technique. (A) Angiography of the bilateral iliofemoral arteries before starting the percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) procedure. (B, C) Left and right common femoral artery puncture with 83-mm-length needles (dotted lines) using 0.035-in. and 0.014-in. wires (arrows) as landmarks, respectively. (D) Transcatheter heart valve (arrow) implantation by right TF-TAVI with a left percutaneous transfemoral intra-aortic balloon pump (dotted line). (E) Angiography of the right iliofemoral artery with a 14-Fr expandable sheath (dotted line). (F) Inflation of an 8.0-mm-diameter over-the-wire balloon (dotted line) with a 0.035-in.-diameter central lumen over a 0.014-in. guidewire in the right external iliac artery. (G) Contrast injection via the central balloon lumen with the over-the-wire balloon in the right external iliac artery. (H) Inflation of the same balloon (dotted line) over a 0.035-in. guidewire in the left external iliac artery. OTW, over-the-wire.
[10] Buchanan GL, Chieffo A, Montorfano M, Maccagni D, Maisano F, Latib A, et al. A “modified crossover technique” for vascular access management in high-risk patients undergoing transfemoral transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2013;81(4):579–83. [11] Curran H, Chieffo A, Buchanan GL, Bernelli C, Montorfano M, Maisano F, et al. A comparison of the femoral and radial crossover techniques for vascular access management in transcatheter aortic valve implantation: the Milan experience. Catheter Cardiovasc Interv 2014;83(1):156–61.
[12] Hibbert B, Simard T, Wilson KR, Hawken S, Wells GA, Ramirez FD, et al. Transradial versus transfemoral artery approach for coronary angiography and percutaneous coronary intervention in the extremely obese. JACC Cardiovasc Interv 2012;5(8):819–26. [13] Kodama A, Yamamoto M, Shimura T, Kagase A, Koyama Y, Tada N, et al. Comparative data of single versus double proglide vascular preclose technique after percutaneous transfemoral transcatheter aortic valve implantation from the optimized catheter valvular intervention (OCEAN-TAVI) Japanese multicenter registry. Catheter Cardiovasc Interv 2016.
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Fig. 4. Illustration of Fig. 3G. There was a residual space at the 0.035-in.-diameter central balloon lumen of the over-the-wire balloon over the 0.014-in. guidewire across the right iliofemoral artery. This space enabled low-dose contrast to be injected with the guidewire left in the true lumen of the right iliofemoral artery and without retraction of the balloon. OTW, over-the-wire; EIA, external iliac artery; CFA, common femoral artery; DFA, deep femoral artery; SFA, superficial femoral artery.
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Case Reports
A “double crossover technique” in an obese patient undergoing transfemoral transcatheter aortic valve implantation: How to accomplish hemostasis percutaneously? Hirokazu Onishi, Toru Naganuma, Sunao Nakamura ⁎ Department of Cardiology, New Tokyo Hospital, Chiba, Japan
a r t i c l e
i n f o
Article history: Received 28 February 2017 Received in revised form 22 March 2017 Accepted 29 March 2017 Keywords: Crossover technique Obesity Transcatheter aortic valve implantation Intra-aortic balloon pump
a b s t r a c t Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure but may be associated with vascular complications at femoral access sites, particularly in obese patients. This report aimed to describe a case of successful performance of our “double crossover technique” in an obese patient undergoing TF-TAVI with a percutaneous transfemoral intra-aortic balloon pump (TF-IABP). A 75-yearold man presented with heart failure due to a left ventricular ejection fraction of 35% and low-flow, lowgradient severe aortic stenosis. The logistic EuroSCORE and STS-PROM score were 31.38% and 7.311%, respectively. Right TF-TAVI using a 14-Fr expandable sheath and a left TF-IABP using an 8-Fr sheath were scheduled. The patient was obese, with a body mass index of 31.7 kg/m2, and we expected access site-related vascular complications to occur. Subsequently, we performed a femoral and brachial crossover technique, called the “double crossover technique,” at the completion of the TAVI procedure: first, for the right common femoral artery (CFA) through the sheath in the left CFA and second, for the left CFA through the sheath in the right brachial artery. In the crossover technique, an 8.0-mm-diameter over-the-wire balloon was advanced to an external iliac artery and was subsequently inflated when the sheath was removed. For the right CFA, a double preclose technique was used with the crossover technique. There was no evidence of access site-related vascular complications following TAVI. The double crossover technique was effective at achieving hemostasis and avoiding access site-related vascular complications in an obese patient undergoing TF-TAVI with a TF-IABP. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure in patients at intermediate and high surgical risk [1–4]. However, access site-related major vascular complications in TF-TAVI, defined according to the Valve Academic Research Consortium-2 criteria, are not rare and are associated with increased morbidity and mortality [5,6]. When TAVI is performed in patients with left ventricular systolic dysfunction, the use of mechanical circulatory support devices during TAVI, such as a percutaneous transfemoral intra-aortic balloon pump (TF-IABP) and an extracorporeal membrane oxygenation device, is considered helpful [7]. Access site-related vascular complications are expected to be frequent in obese patients undergoing TF-TAVI with mechanical circulatory support devices. The femoral crossover technique and radial crossover technique are successful and useful methods
Abbreviations: TF-TAVI, transfemoral transcatheter aortic valve implantation; TF-IABP, transfemoral intra-aortic balloon pump. ⁎ Corresponding author at: New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 2702232, Japan. Tel.: +81 47 366 7000; fax: +81 47 392 8718. E-mail address: [email protected] (S. Nakamura). http://dx.doi.org/10.1016/j.carrev.2017.03.030 1553-8389/© 2017 Elsevier Inc. All rights reserved.
of accomplishing hemostasis and avoiding access site-related vascular complications following TAVI [8–11]. This report aimed to describe a case of successful femoral and brachial crossover technique, called the “double crossover technique,” in an obese patient undergoing TF-TAVI with a TF-IABP. 2. Case A 75-year-old man presented with worsening chronic heart failure due to low-flow, low-gradient severe aortic stenosis and was admitted to our hospital. Echocardiography revealed a left ventricular ejection fraction of 35%, an aortic valve area of 0.73 cm2, a mean pressure gradient across the aortic valve of 31 mmHg, and no significant aortic regurgitation. The patient had some comorbidities: paroxysmal atrial fibrillation, non-insulin-dependent diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease. There were no findings of ischemic heart disease. The logistic EuroSCORE and the STSPROM score were 31.38% and 7.311%, respectively. According to contrast-enhanced computed tomography, there was no contraindication in the bilateral femoral access routes for TF-TAVI (Fig. 1). The minimum lumen diameters of the right external iliac artery (EIA) and the right common femoral artery (CFA) were 7.1 and 5.8 mm,
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441
procedure. The 14-Fr expandable sheath was inserted into the right CFA, and an IABP (Xemex IABP Balloon Plus, Zeon, Tokyo, Japan) was inserted into the 8-Fr left CFA sheath. Right TF-TAVI was performed to implant a transcatheter heart valve (SAPIEN 3 26 mm, Edwards Lifesciences) successfully (Fig. 3D). The TAVI delivery system and the IABP were removed with the patient stable hemodynamically. Angiography of the right iliofemoral artery showed no findings of access site-related vascular complications (Fig. 3E). We then proceeded to the double crossover technique. First, the femoral crossover technique was performed. A semicompliant overthe-wire balloon (Mustang Balloon 8.0 × 40 mm, Boston Scientific, Boston, MA, USA) with a 0.035-in.-diameter central lumen was advanced over the 0.014-in. guidewire through the left CFA sheath into the right EIA just proximal to the right CFA e-sheath and was subsequently inflated to a pressure of 8 atm in 3 min with manual compression at removal of the sheath (Fig. 3F). For the right CFA, the double preclose technique was performed with the crossover technique. By injecting contrast via the central balloon lumen with the over-the-wire balloon in the right EIA, we confirmed that there were no findings of access site-related bleeding or vascular complications (Figs. 3G and 4). Second, the brachial crossover technique was performed; the same balloon was advanced over the 0.035-in. hydrophilic guidewire through the right BA sheath into the left EIA just proximal to the left CFA sheath and was inflated to a pressure of 8 atm in 7 min with manual compression at removal of the sheath (Fig. 3H). The final angiography and postprocedural course showed that there was no evidence of periprocedural access site-related vascular complications. Echocardiography showed an improved left ventricular ejection fraction of 50%, a mean pressure gradient across the aortic valve of 8 mmHg, and no findings of significant paravalvular leakage. The patient restarted warfarin the next day and was discharged 10 days later following TAVI. 3. Discussion Fig. 1. Three-dimensional computed tomographic angiography of the aorta to the bilateral iliofemoral arteries.
respectively. Right TF-TAVI using a 14-Fr expandable sheath (e-Sheath, Edwards Lifesciences, Irvine, CA, USA) was scheduled with a preprocedural left TF-IABP using an 8-Fr sheath because of left ventricular systolic dysfunction. The patient gave informed consent for the procedure before it began. The patient received antithrombotic therapy with aspirin 100 mg/ day and warfarin. Warfarin was stopped and heparinization was started 3 days before TAVI. Heparinization was stopped 6 h before starting TAVI. The patient was 173 cm tall and weighed 95 kg, with a body mass index of 31.7 kg/m 2, indicating obesity. As shown by computed tomography, the estimated distance between the skin and the right CFA puncture was at least 70 mm (Fig. 2). We expected that vascular complications at the femoral access sites could occur. Therefore, we performed TFTAVI using the “double crossover technique” in the following manner, with the patient under general anesthesia (Fig. 3). Angiography of the aorta to the bilateral iliofemoral arteries was performed with a pigtail catheter via a 6-Fr sheath in the right brachial artery (BA) (Fig. 3A). A 0.035-in. hydrophilic guidewire (Radifocus Guidewire, Terumo, Tokyo, Japan) was advanced through the sheath to the left popliteal artery. Left CFA puncture was performed with an 83-mm-length needle using the 0.035-in. guidewire as a landmark (Fig. 3B). An 8-Fr sheath was inserted into the left CFA, through which a 0.014-in. hydrophilic guidewire (Cruise Guidewire, Asahi Intecc, Nagoya, Japan) was advanced to the right popliteal artery. Right CFA puncture was performed with an 83-mm-length needle using the 0.014-in. guidewire as a landmark (Fig. 3C). Two percutaneous closure devices (Perclose ProGlide, Abbott Vascular, Santa Clara, CA, USA) were prepared for the double preclose technique at the completion of the TAVI
In obese patients undergoing coronary angiography or percutaneous coronary intervention, access site-related bleeding and vascular complications are reportedly more frequent with the transfemoral approach than with the transradial approach [12]. These complications are expected to be frequent in obese patients undergoing TF-TAVI with transfemoral mechanical circulatory support devices that are helpful for patients with left ventricular systolic dysfunction [7]. In the present obese patient undergoing TF-TAVI with a TF-IABP, we performed the double crossover technique with the double preclose technique. There are three main advantages of the crossover technique: 1) secure CFA puncture with a guidewire across the CFA as a landmark, 2) successful hemostasis with balloon inflation at femoral access sites, and 3) instant detection and subsequent treatment for access siterelated vascular complications with an over-the-wire balloon. 1) Secure CFA puncture with a guidewire across the CFA as a landmark. In the present case, computed tomography showed that the estimated distance between the skin and the site of the right CFA puncture with a needle was at least 70 mm (Fig. 2). Therefore, at the start of the TF-TAVI procedure, we needed an 83-mmlength needle to puncture the CFA. By using a guidewire across the CFA as a landmark, we achieved CFA puncture securely to avoid access site-related vascular complications [8,10]. 2) Successful hemostasis with balloon inflation at femoral access sites. In the crossover technique after transcatheter heart valve implantation, an over-the-wire balloon over a guidewire across a CFA is advanced into the ipsilateral EIA just proximal to the CFA sheath. At removal of the CFA sheath, the balloon is inflated at the ipsilateral EIA with manual compression for hemostasis of the femoral access site. The femoral crossover technique has a
442
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Fig. 2. (A, B) Axial computed tomographic images of the abdominal area. (C) Sagittal computed tomographic image of the abdominal area. The red dotted lines indicate the levels of panels A and B. The blue dotted line indicates the estimated distance between the skin and the site where the right common femoral artery was punctured with a needle.
high procedural success rate and reduces the rates of access siterelated bleeding and major vascular complications, leading to decreased mortality following TAVI [9]. Furthermore, the radial crossover technique is a reasonable alternative to the femoral crossover technique [11]. It is considered useful for patients in whom the contralateral femoral artery is anatomically unfavorable or is already in use. 3) Instant detection and subsequent treatment for access siterelated vascular complications with an over-the-wire balloon. There is a residual space at a 0.035-in.-diameter central balloon lumen of an over-the-wire balloon over a 0.014-in. guidewire across an iliofemoral artery. This space enables low-dose contrast to be injected with the guidewire left in the true lumen of the iliofemoral artery and without retraction of the balloon. Therefore, the crossover technique is also useful for enabling instant detection and subsequent treatment of access site-related vascular complications at the completion of the TF-TAVI procedure.
3.1. The double preclose technique in addition to the crossover technique in obese patients The rate of access site-related vascular complications is not significantly different between patients undergoing the double and single preclose techniques [13]. However, the study mainly included patients with normal body mass indexes. For obese patients undergoing TFTAVI, the double preclose technique may be helpful in case of single preclose failure. It is expected that hematoma of the femoral access sites may not be detected instantly and that adequate manual compression may be difficult to perform in obese patients.
4. Conclusion The double crossover technique was effective at achieving hemostasis and avoiding access site-related vascular complications of the puncture site in an obese patient undergoing TF-TAVI with a TF-IABP. References [1] Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. (1533-4406 (Electronic)). [2] Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374(17):1609–20. [3] Biancari F, Rosato S, D'Errigo P, Ranucci M, Onorati F, Barbanti M, et al. Immediate and intermediate outcome after transapical versus transfemoral transcatheter aortic valve replacement. Am J Cardiol 2016;117(2):245–51. [4] Frohlich GM, Baxter PD, Malkin CJ, Scott DJ, Moat NE, Hildick-Smith D, et al. Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry). Am J Cardiol 2015;116(10):1555–9. [5] Genereux P, Webb JG, Svensson LG, Svensson LG, Kodali SK, Kodali SK, Satler LF, Satler LF, Fearon WF, Fearon WF, Davidson CJ, Davidson CJ, Eisenhauer AC, Eisenhauer AC, Makkar RR, Makkar RR, Bergman GW, Bergman GW, Babaliaros V, et al. Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial. (1558-3597 (Electronic)). [6] Kappetein AP, Head SJ, Genereux P, Piazza N, van Mieghem NM, Blackstone EH, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. J Thorac Cardiovasc Surg 2013;145(1):6–23. [7] Singh V, Damluji AA, Mendirichaga R, Alfonso CE, Martinez CA, Williams D, et al. Elective or emergency use of mechanical circulatory support devices during transcatheter aortic valve replacement. J Interv Cardiol 2016;29(5):513–22. [8] Sharp AS, Michev I, Maisano F, Taramasso M, Godino C, Latib A, et al. A new technique for vascular access management in transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2010;75(5):784–93. [9] Zaman S, Gooley R, Cheng V, McCormick L, Meredith IT. Impact of routine crossover balloon occlusion technique on access-related vascular complications following transfemoral transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2016;88(2):276–84.
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Fig. 3. Double crossover technique. (A) Angiography of the bilateral iliofemoral arteries before starting the percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) procedure. (B, C) Left and right common femoral artery puncture with 83-mm-length needles (dotted lines) using 0.035-in. and 0.014-in. wires (arrows) as landmarks, respectively. (D) Transcatheter heart valve (arrow) implantation by right TF-TAVI with a left percutaneous transfemoral intra-aortic balloon pump (dotted line). (E) Angiography of the right iliofemoral artery with a 14-Fr expandable sheath (dotted line). (F) Inflation of an 8.0-mm-diameter over-the-wire balloon (dotted line) with a 0.035-in.-diameter central lumen over a 0.014-in. guidewire in the right external iliac artery. (G) Contrast injection via the central balloon lumen with the over-the-wire balloon in the right external iliac artery. (H) Inflation of the same balloon (dotted line) over a 0.035-in. guidewire in the left external iliac artery. OTW, over-the-wire.
[10] Buchanan GL, Chieffo A, Montorfano M, Maccagni D, Maisano F, Latib A, et al. A “modified crossover technique” for vascular access management in high-risk patients undergoing transfemoral transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2013;81(4):579–83. [11] Curran H, Chieffo A, Buchanan GL, Bernelli C, Montorfano M, Maisano F, et al. A comparison of the femoral and radial crossover techniques for vascular access management in transcatheter aortic valve implantation: the Milan experience. Catheter Cardiovasc Interv 2014;83(1):156–61.
[12] Hibbert B, Simard T, Wilson KR, Hawken S, Wells GA, Ramirez FD, et al. Transradial versus transfemoral artery approach for coronary angiography and percutaneous coronary intervention in the extremely obese. JACC Cardiovasc Interv 2012;5(8):819–26. [13] Kodama A, Yamamoto M, Shimura T, Kagase A, Koyama Y, Tada N, et al. Comparative data of single versus double proglide vascular preclose technique after percutaneous transfemoral transcatheter aortic valve implantation from the optimized catheter valvular intervention (OCEAN-TAVI) Japanese multicenter registry. Catheter Cardiovasc Interv 2016.
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Fig. 4. Illustration of Fig. 3G. There was a residual space at the 0.035-in.-diameter central balloon lumen of the over-the-wire balloon over the 0.014-in. guidewire across the right iliofemoral artery. This space enabled low-dose contrast to be injected with the guidewire left in the true lumen of the right iliofemoral artery and without retraction of the balloon. OTW, over-the-wire; EIA, external iliac artery; CFA, common femoral artery; DFA, deep femoral artery; SFA, superficial femoral artery.