Presentations

Abstract

Introduction: The use of Transcatheter Aortic Valve Replacement (TAVR) has emerged as the new standard of care in elderly patients with severe aortic valve stenosis. One of the major concerns with TAVR is vascular complications secondary to large bore sheath placement1 and vascular closure devices. This report presents a TAVR case which led to an arterial access site dissection and occlusion. Attempted endovascular management was unsuccessful and led to additional complications for the patient and ultimately required open repair.

Case Information: An 80-year-old female who had prohibitively high surgical risk was scheduled for TAVR procedure. A 23 mm Edwards SAMPIEN 3 valve was successfully deployed through right common femoral arterial access through a 14 Fr sheath. MANTA closure device was deployed to close the right CFA. Completion angiogram via left CFA access revealed a discrete dissection flap in the right external iliac artery with minimal distal perfusion. Multiple prolonged attempts to cross the dissection with a wire and catheter technique were performed with apparent success. Balloon angioplasty revealed no improvement in distal flow but persistence of the dissection flap, prompting placement of an uncovered stent. Completion angiogram showed complete arterial occlusion with no flow through the stent. Vascular surgery was consulted and initiated a right groin exploration procedure.

Discussion/Clinical Findings: On exposure of the right common femoral artery, the stent was visualized traversing the common femoral artery wall into an extraluminal hematoma. Arteriotomy was performed in the right common femoral artery extending to the superficial femoral artery. The stent and MANTA closure device were both removed. Endarterectomy and bovine patch angioplasty were performed. Flow was restored to the RLE with confirmation by angiogram and the patient was discharged POD 3.

Conclusion: External iliac dissection due to large devices in small and/or diseased iliac arteries is a common occurrence. In this case, attempted percutaneous management created a false passage transmurally into the intermuscular space. Angioplasty was followed by transmural stent deployment resulting in hematoma and acute limb ischemia. Femoral endarterectomy and patch angioplasty after removal of the transmural stent led to a positive patient outcome. It can be seen that multiple, prolonged attempts to avoid open repair for this patient ultimately led to additional procedural time and adverse events. Despite the patient's high operative risks, she did well with a local incision and direct repair. Vascular complications during TAVR procedure are not uncommon. This case highlights the benefit from multidisciplinary teams assisting when complications arise in these medically complex patients and early vascular surgical consultation is imperative for positive patient outcome.