- Email: [email protected]
Transfemoral Edwards SAPIEN Aortic Valve Implantation Through Aortofemoral Endograft
Canadian Journal of Cardiology
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(2014) 1.e1e1.e3 www.onlinecjc.ca
Case Report
Transfemoral Edwards SAPIEN Aortic Valve Implantation Through Aortofemoral Endograft Jaya Chandrasekhar, MD,a Buu-Khanh Lam, MD,b and Chris Glover, MDa a b
Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Department of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
ABSTRACT
RESUM E
We present the case of an 86-year-old woman with an aortobifemoral endograft and porcelain aorta who underwent transfemoral transcatheter aortic valve implantation (TAVI). A femoral cutdown was performed to the left limb of the endograft, and the needle puncture into the graft required sequential incisions and dilation to allow access of the 18F Edwards SAPIEN expandable eSheath (Edwards Lifesciences, Irvine, CA). A 26-mm Edwards SAPIEN transcatheter aortic valve was then successfully deployed. The cutdown was closed and hemostasis was achieved without any iatrogenic narrowing of the graft. Transfemoral TAVI through surgical cutdown with dilation of a femoral endograft is safe and feasible.
sentons le cas d’une femme de 86 ans ayant une endogreffe Nous pre morale et une aorte porcelaine qui a subi par voie fe morale aortobife ter (IVAC). Une une implantation valvulaire aortique par cathe nudation fe morale a e te re alise e à la branche gauche de l’ende cessite des indogreffe, et la ponction à l’aiguille dans la greffe a ne quentielles et une expansion pour permettre l’accès à la cisions se gaine d’introduction extensible 18F Edwards SAPIEN (Edwards Lifeter Edwards SAPIEN sciences, Irvine, CA). Une valve aortique transcathe te de ploye e avec succès. La de nudation a e te de 26 mm a ensuite e e et l’he mostase a e te obtenue sans re tre cissement iatrogène ferme morale par de nudation chirurgicale et de la greffe. L’IVAC transfe morale est sûre et re alisable. expansion de l’endoprothèse fe
We present the case of an 86-year-old woman with an aortobifemoral endograft and porcelain aorta who underwent transfemoral transcatheter aortic valve implantation (TAVI).
Computed tomography (Fig. 1) showed significant native iliac disease with patent aortobifemoral grafts. The right femoral artery measured 10 9 mm and the left femoral artery measured 9 9 mm. The ascending aorta was porcelain with an aortic annulus size of 23 24 mm and an annulus area of 440 mm2. The calculated Society of Thoracic Surgeons score was 6.7% and the logistic EuroSCORE was 19.85%. A decision was made for conservative management of the circumflex disease and TAVI through a transfemoral approach. Angiographically, the mean diameter of the right common femoral artery was 9 mm at the time of the TAVI procedure, and the left femoral artery was comparable in size , view video online). (Video 1 A left femoral cutdown was performed and the left limb of the aortobifemoral graft was dissected. A purse-string suture using pledgeted 4-0 polypropylene was placed on the anterior surface of the left limb proximal to its anastomosis with the native femoral artery, and the left limb was punctured with a 18G Cook needle followed by sequential dilation of the graft opening from 10-18F over a J wire with progressive incisions on the graft. After heparinization, the Edwards SAPIEN transfemoral expandable sheath (eSheath), with an outer diameter of 7.2 mm and an inner diameter of 5.9 mm, was inserted and advanced under fluoroscopic guidance. Aortic valvuloplasty with a NuMed (Cornwall, Ontario, Canada) 18 mm 4 cm balloon catheter was followed by successful
Case Presentation An 86-year-old woman presented with New York Heart Association class III dyspnea and severe aortic valve stenosis. Echocardiography showed normal left ventricular systolic function with a left ventricular outflow tract diameter of 18 mm and an aortic valve mean gradient of 44 mm Hg, with a valve area of 0.84 cm2. Coronary angiography performed through radial access showed a discrete 90% lesion in the marginal circumflex branch. The patient had a history of aortobifemoral graft surgery, and a bifurcated Hemashield (Maquet Getinge Group, Rastatt, Germany) 14 7 mm endograft extended from the distal aorta to both common femoral arteries. The surgery was performed for left iliac artery occlusion and an ischemic left foot, multiple right iliac artery lesions, and a 3.5-cm infrarenal abdominal aortic aneurysm. Received for publication October 4, 2013. Accepted February 11, 2014. Corresponding author: Dr Jaya Chandrasekhar, 40 Ruskin Street, University of Ottawa Heart Institute, Ottawa, Ontario K1Y 1J7, Canada. Tel.: þ1-613-761-4119; fax: þ1-613-761-4705. E-mail: [email protected] See page 1.e3 for disclosure information.
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2014.02.004
1.e2
Canadian Journal of Cardiology Volume - 2014
Figure 1. Pre-TAVI computed tomographic scans. (A) Arrows indicate the aortobifemoral endografts. Extensive vascular calcification in the entire extent of the aorta is noted. (B) Arrow indicates porcelain aorta.
implantation of a 26-mm Edwards SAPIEN XT valve in the usual manner. Under controlled hemodynamics, the sheath was removed and the purse-string suture was tied down. Good hemostasis was obtained, and a confirmation angiogram
, view video did not show any graft narrowing (Video 2 online). The left femoral cutdown was then closed in a standard fashion. Fig 2 shows images of iliofemoral angiography before and after TAVI.
Figure 2. Iliofemoral angiography before and after TAVI. (A) Patent aortobifemoral grafts (double arrow) with minimal disease before TAVI. (B) Angiogram of left femoral endograft access site (arrow) after TAVI.
Chandrasekhar et al. TAVI Through Aortofemoral Endograft
Discussion Peripheral artery disease is a major comorbidity in patients referred for TAVI.1 When access is precluded by iliofemoral disease, several alternative routes have been successfully used, including transapical, direct aortic, and subclavian approaches (see Supplemental Discussion). Transfemoral access, however, remains the most commonly used approach. We found only 1 report of percutaneous TAVI through an aortoiliac graft,2 and to our knowledge this is the first description of TAVI facilitated by surgical cutdown to an aortofemoral graft. The chief concerns with gaining femoral endograft access are the need for dilation at the graft puncture site to allow large sheath entry, success of suture-mediated arterial pre-closure, and subsequent integrity of the graft and need for urgent vascular repair. In this case, we felt surgical cutdown was favorable to percutaneous access to allow graft entry, dilation, and closure under direct vision. The procedure time was not significantly prolonged with this approach, and in-hospital recovery was uneventful. At 6-month follow-up, the patient remained well. This case demonstrates that TAVI through a cutdown to an endovascular femoral graft is feasible without affecting the immediate and long-term integrity of the graft. A successful operative liaison with cardiac surgeons facilitates access through multiple routes for TAVI, including transfemoral access requiring vascular cutdown and closure. Furthermore, it facilitates rapid conversion to sternotomy and cardiac bypass
1.e3
when this is required in an emergency in the catheterization laboratory. Acknowledgements The authors thank C. Dennie, MD, The Ottawa Hospital, for interpretation of computed tomographic scans. Disclosures The authors have no conflicts of interest to disclose. References 1. Ben-Dor I, Waksman R, Hanna NN, et al. Utility of radiologic review for noncardiac findings on multislice computed tomography in patients with severe aortic stenosis evaluated for transcatheter aortic valve implantation. Am J Cardiol 2010;105:1461-4. 2. Gul M, Akgul O, Erturk M, Eksik A, Yildirim A. Transcatheter aortic valve implantation through a left aortoiliac graft. Tex Heart Inst J 2012;39:898-900.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.02.004.
-
(2014) 1.e1e1.e3 www.onlinecjc.ca
Case Report
Transfemoral Edwards SAPIEN Aortic Valve Implantation Through Aortofemoral Endograft Jaya Chandrasekhar, MD,a Buu-Khanh Lam, MD,b and Chris Glover, MDa a b
Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Department of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
ABSTRACT
RESUM E
We present the case of an 86-year-old woman with an aortobifemoral endograft and porcelain aorta who underwent transfemoral transcatheter aortic valve implantation (TAVI). A femoral cutdown was performed to the left limb of the endograft, and the needle puncture into the graft required sequential incisions and dilation to allow access of the 18F Edwards SAPIEN expandable eSheath (Edwards Lifesciences, Irvine, CA). A 26-mm Edwards SAPIEN transcatheter aortic valve was then successfully deployed. The cutdown was closed and hemostasis was achieved without any iatrogenic narrowing of the graft. Transfemoral TAVI through surgical cutdown with dilation of a femoral endograft is safe and feasible.
sentons le cas d’une femme de 86 ans ayant une endogreffe Nous pre morale et une aorte porcelaine qui a subi par voie fe morale aortobife ter (IVAC). Une une implantation valvulaire aortique par cathe nudation fe morale a e te re alise e à la branche gauche de l’ende cessite des indogreffe, et la ponction à l’aiguille dans la greffe a ne quentielles et une expansion pour permettre l’accès à la cisions se gaine d’introduction extensible 18F Edwards SAPIEN (Edwards Lifeter Edwards SAPIEN sciences, Irvine, CA). Une valve aortique transcathe te de ploye e avec succès. La de nudation a e te de 26 mm a ensuite e e et l’he mostase a e te obtenue sans re tre cissement iatrogène ferme morale par de nudation chirurgicale et de la greffe. L’IVAC transfe morale est sûre et re alisable. expansion de l’endoprothèse fe
We present the case of an 86-year-old woman with an aortobifemoral endograft and porcelain aorta who underwent transfemoral transcatheter aortic valve implantation (TAVI).
Computed tomography (Fig. 1) showed significant native iliac disease with patent aortobifemoral grafts. The right femoral artery measured 10 9 mm and the left femoral artery measured 9 9 mm. The ascending aorta was porcelain with an aortic annulus size of 23 24 mm and an annulus area of 440 mm2. The calculated Society of Thoracic Surgeons score was 6.7% and the logistic EuroSCORE was 19.85%. A decision was made for conservative management of the circumflex disease and TAVI through a transfemoral approach. Angiographically, the mean diameter of the right common femoral artery was 9 mm at the time of the TAVI procedure, and the left femoral artery was comparable in size , view video online). (Video 1 A left femoral cutdown was performed and the left limb of the aortobifemoral graft was dissected. A purse-string suture using pledgeted 4-0 polypropylene was placed on the anterior surface of the left limb proximal to its anastomosis with the native femoral artery, and the left limb was punctured with a 18G Cook needle followed by sequential dilation of the graft opening from 10-18F over a J wire with progressive incisions on the graft. After heparinization, the Edwards SAPIEN transfemoral expandable sheath (eSheath), with an outer diameter of 7.2 mm and an inner diameter of 5.9 mm, was inserted and advanced under fluoroscopic guidance. Aortic valvuloplasty with a NuMed (Cornwall, Ontario, Canada) 18 mm 4 cm balloon catheter was followed by successful
Case Presentation An 86-year-old woman presented with New York Heart Association class III dyspnea and severe aortic valve stenosis. Echocardiography showed normal left ventricular systolic function with a left ventricular outflow tract diameter of 18 mm and an aortic valve mean gradient of 44 mm Hg, with a valve area of 0.84 cm2. Coronary angiography performed through radial access showed a discrete 90% lesion in the marginal circumflex branch. The patient had a history of aortobifemoral graft surgery, and a bifurcated Hemashield (Maquet Getinge Group, Rastatt, Germany) 14 7 mm endograft extended from the distal aorta to both common femoral arteries. The surgery was performed for left iliac artery occlusion and an ischemic left foot, multiple right iliac artery lesions, and a 3.5-cm infrarenal abdominal aortic aneurysm. Received for publication October 4, 2013. Accepted February 11, 2014. Corresponding author: Dr Jaya Chandrasekhar, 40 Ruskin Street, University of Ottawa Heart Institute, Ottawa, Ontario K1Y 1J7, Canada. Tel.: þ1-613-761-4119; fax: þ1-613-761-4705. E-mail: [email protected] See page 1.e3 for disclosure information.
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2014.02.004
1.e2
Canadian Journal of Cardiology Volume - 2014
Figure 1. Pre-TAVI computed tomographic scans. (A) Arrows indicate the aortobifemoral endografts. Extensive vascular calcification in the entire extent of the aorta is noted. (B) Arrow indicates porcelain aorta.
implantation of a 26-mm Edwards SAPIEN XT valve in the usual manner. Under controlled hemodynamics, the sheath was removed and the purse-string suture was tied down. Good hemostasis was obtained, and a confirmation angiogram
, view video did not show any graft narrowing (Video 2 online). The left femoral cutdown was then closed in a standard fashion. Fig 2 shows images of iliofemoral angiography before and after TAVI.
Figure 2. Iliofemoral angiography before and after TAVI. (A) Patent aortobifemoral grafts (double arrow) with minimal disease before TAVI. (B) Angiogram of left femoral endograft access site (arrow) after TAVI.
Chandrasekhar et al. TAVI Through Aortofemoral Endograft
Discussion Peripheral artery disease is a major comorbidity in patients referred for TAVI.1 When access is precluded by iliofemoral disease, several alternative routes have been successfully used, including transapical, direct aortic, and subclavian approaches (see Supplemental Discussion). Transfemoral access, however, remains the most commonly used approach. We found only 1 report of percutaneous TAVI through an aortoiliac graft,2 and to our knowledge this is the first description of TAVI facilitated by surgical cutdown to an aortofemoral graft. The chief concerns with gaining femoral endograft access are the need for dilation at the graft puncture site to allow large sheath entry, success of suture-mediated arterial pre-closure, and subsequent integrity of the graft and need for urgent vascular repair. In this case, we felt surgical cutdown was favorable to percutaneous access to allow graft entry, dilation, and closure under direct vision. The procedure time was not significantly prolonged with this approach, and in-hospital recovery was uneventful. At 6-month follow-up, the patient remained well. This case demonstrates that TAVI through a cutdown to an endovascular femoral graft is feasible without affecting the immediate and long-term integrity of the graft. A successful operative liaison with cardiac surgeons facilitates access through multiple routes for TAVI, including transfemoral access requiring vascular cutdown and closure. Furthermore, it facilitates rapid conversion to sternotomy and cardiac bypass
1.e3
when this is required in an emergency in the catheterization laboratory. Acknowledgements The authors thank C. Dennie, MD, The Ottawa Hospital, for interpretation of computed tomographic scans. Disclosures The authors have no conflicts of interest to disclose. References 1. Ben-Dor I, Waksman R, Hanna NN, et al. Utility of radiologic review for noncardiac findings on multislice computed tomography in patients with severe aortic stenosis evaluated for transcatheter aortic valve implantation. Am J Cardiol 2010;105:1461-4. 2. Gul M, Akgul O, Erturk M, Eksik A, Yildirim A. Transcatheter aortic valve implantation through a left aortoiliac graft. Tex Heart Inst J 2012;39:898-900.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.02.004.