Trans-brachial TAVI in patient with aortic isthmus stenosis: a case report

• Present history: 83 years old male patient with dyspnoe NYHA III

• Past history: known aortic isthmus stenosis, chronic renal disease

• CVRF: arterial hypertension, obesity with BMI 35 

• ECG: Sinus rythsm, incomplete right bundle branch block, QRS duration 115 ms

• Echocardiography: HFpEF ca. 55%

   severe aortic stenosis, Pmean 45 mmHg, Pmax 65 mmHg

   Aortic valve area (AVA) 0.85 cm2

• Coronary angiography: atherosclerotic noncritical coronary artery disease CT-Aortography analysis

 

Aortic valve: trileaflet anatomy asymmetric calcification of non-coronary cusp annulus perimeter of 79,7 mm, area 492,8 cm2

The angle between the aorta and left subclavian artery, was appropriate for TAVI. 

 

CT-Aortography revealed aortic isthmus stenosis directly after left subclavian artery origin.

Duplex sonography of brachial artery: brachial artery diameter of 55 mm. 

Heart team consensus

TAVI: preferred (EuroSCORE II: 10.6%; STS score Mortality: 10.9%) Access site: 

• Transfemoral and trans caval: excluded due to aortic isthmus stenosis 

• Trans-carotis: not preferred due to atherosclerosis of both carotis arteries ( risk of embolization) 

• Transaortic: not preferred (old age, comorbidity, and invasiveness of the procedure) 

• Trans-subclavian and trans-axillary: not preferred due to thoracic collaterals, access through both arteries carry risk of collaterals injury 

Trans-septal: complex and longer way 

Brachial artery: feasible with diameter of 55 mm selected after meticulous planning of the procedure and patient´s consent

 

Trans-brachial TAVI

Exploration of brachial artery by surgical cutdown 

14 F sheath was passed to the ascending aorta ascending aorta 

Implantation of  Evolut PRO+ TAVI

 

Balloon valvuloplasty successfully implanted a Medtronic Evolut PRO+ prosthetic valve with a size of 29 mm with the Cusp-Overlap technique. 

No paravalvular or valvular regurgitation on the control aortography 

Technical considerations

• Preoperative computed tomography scan is mandatory for screening for suitability, vessel diameter, tortuosity, the relationship with side branches, calcifications and device selection.

• The left brachial artery is preferred due to better coaxial orientation, decreases the chance of carotid compromise, advantageous in right-handed patients. 

• The left brachial artery reached in this case by surgical cutdown.

• An extra stiff guidewire like Linderquist is preferred.

• Do not persist to push the delivery sheath to the end.

Technical considerations

• An angle > 30° between the annular plane and the right subclavian horizontal axis or > 70° between the annular plane and the left subclavian (i.e., "horizontal aorta") typically means a contraindication due to difficulties in achieving coaxiality.

• Type 1 arch: a reason to avoid a right-sided approach, especially if the innominate artery arises distal on the arch. 

• On the other hand, left-sided access may be challenging if the left subclavian artery is retroflexed towards the descending aorta, or with a steep subclavian to arch angulation (> 80°).

• Patient with a patent left internal mammary artery (LIMA) coronary bypass graft, a minimal vessel diameter of 7-8 mm proximal to or at the ostium of the LIMA, are essential in order to prevent myocardial ischemia.