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

Mohammed Saad (Kiel)1, A. Elhakim (Kiel)1, D. Frank (Kiel)1

1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland


Clinical Presentation
• 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.
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