Mitral transcatheter edge-to-edge repair with MitraClip in severely turtuous vena cava inferior and ilical veins

An 84-year-old woman with a history of severe mitral regurgitation secondary to a P2/P3 flail was referred for mitral valve repair using the MitraClip system (Abbott Vascular, USA) (Fig. 1). After completing the necessary diagnostic work-up, the decision was made to proceed with mitral transcatheter edge-to-edge repair (M-TEER).

 

The procedure initially encountered difficulties during the transseptal puncture (TSP). Attempts to perform TSP with an SL-1 sheath and manually curved Brockenbrough needle were unsuccessful, as three sheaths were perforated while advancing the needle due to significant kinking at the transition of the iliac vein into the inferior vena cava. To overcome this, a 14 Fr. Sentrant sheath (Medtronic, Ireland) was inserted via a Lunderquist wire to facilitate transseptal needle advancement. However, upon retracting the 14 Fr. dilator, the sheath kinked and ruptured. We changed the access site to the left and proceeded with a 16 Fr. Sentrant sheath, allowing for successful completion of the transseptal puncture. After placing an Amplatzer Superstiff wire in the left superior pulmonary vein, we attempted to advance the 22 Fr. MitraClip guide catheter (GC). However, the catheter could not pass through the iliac vein and inferior vena cava, becoming crushed in the process (Fig. 2).

 

The procedure was halted, and a computed tomography (CT) angiography was performed to assess the underlying vascular anatomy. CT revealed severe kinking of both the inferior vena cava and iliac veins, which prompted a shift in our approach. Based on the findings, we decided to use a 64 cm long, 26 Fr Sentrant sheath, which was advanced through the left iliac vein and successfully navigated into the right atrium.

 

With the sheath in place, the transseptal puncture was successfully performed, and the Amplatzer wire was advanced into the left superior pulmonary vein. The interatrial septum was dilated using a 10x40 mm balloon, and the MitraClip guide catheter was advanced into the left atrium. The mitral valve was successfully treated with one XTW MitraClip, resulting in mild residual mitral regurgitation and mean gradient of 3 mmHg. During sheath retraction, multiple angiograms were performed to ensure there was no evidence of bleeding.

 

This case illustrates the challenges encountered during transcatheter mitral valve repair in patients with severely tortuous venous anatomy. In particular, the tortuosity of the inferior vena cava and iliac veins posed significant obstacles in advancing the transseptal needle and guide catheter. The use of a large-bore 26 Fr. Sentrant sheath allowed for a more stable and controlled approach, ultimately enabling successful completion of the procedure (Fig. 3).

 

Previous studies have highlighted the difficulty of performing transseptal procedures in patients with challenging venous anatomy, emphasizing the need for flexible, tailored approaches. The use of larger and longer sheaths, as demonstrated in this case, can provide greater stability and support, improving procedural success.

 

This case highlights the importance of adapting procedural strategies in the face of complex anatomical challenges. The successful use of a large-bore sheath facilitated transseptal puncture and guide catheter advancement, enabling the successful deployment of the MitraClip in a patient with severely tortuous access. This approach may provide a valuable option for similar cases in the future.