Intravascular Lithotripsy-Assisted Transfemoral TAVI: The Copenhagen Experience and Literature Review

Abstract

Transcatheter aortic valve implantation (TAVI) is currently an established therapy for elderly patients with symptomatic severe aortic valve stenosis across all surgical risk categories. Access is an important aspect when planning for and performing TAVI. The superiority of a transfemoral (TF) approach compared to a transthoracic (transapical, direct aortic) approach has been demonstrated in several studies. Recently, the introduction of intravascular lithotripsy (IVL) has made it possible to treat patients with calcified iliofemoral disease by TF approach. This article aimed to provide a comprehensive overview on the following aspects: (1) preprocedural planning for IVL-assisted TF-TAVI; (2) procedural aspects in IVL-assisted TF-TAVI; (3) outcomes of IVL-assisted TF-TAVI in an experienced TAVI center; and (4) literature review and discussion of this new emerging approach.

Technical Aspects and Development of Transcatheter Aortic Valve Implantation

“…Thus, the calcific lesions of femoral or iliac arteries might be uncrossable even with low-profile catheters, especially if circular calcifications are present. These transform the vessel into a “stiff tube”, which limits arterial expansion to accommodate introducer sheaths or TAVI delivery systems, increasing the risk of dissection or perforation [ 91 ]. Recently, intravascular lithotripsy (Schockwave TM catheter, Schockwave Medical Inc., Santa Clara, CA, USA) has emerged as a treatment option for heavily calcified stenotic lesions, facilitating the transfemoral TAVI approach [ 92 ].…”

Advances in technology and techniques for transcatheter aortic valve replacement with concomitant peripheral arterial disease

“…Patients with focal calcific stenosis <20 mm in length requires a minimal luminal diameter of ≥4.0 and ≥3.0 mm for calcified lesions with a circumference of 360° and 270%, respectively. On the other hand, patients with diffuse calcific stenosis >20 mm in length require a minimal luminal diameter of ≥4.5 and ≥3.5 mm for calcified lesions with a circumference of 360° and 270%, respectively ( 32 ). In a European TAVR registry, intravascular lithotripsy utility increased from 2.4% in 2018 to 6.5% in 2020.…”

Long term follow‐up after balloon expandable covered stents implantation for management of transcatheter aortic valve replacement related vascular access complications

“…While initially reserved to patients at high and intermediate surgical risk, recent data confirmed the safety and efficacy even in low‐risk patients 2,3 . Transfemoral vascular access is the default strategy for TAVR, and it is currently expanding toward more challenging anatomies due to the development of lower‐profile devices, expandable sheaths, and other innovative techniques such as intravascular lithotripsy 4,5 …”

“…2,3 Transfemoral vascular access is the default strategy for TAVR, and it is currently expanding toward more challenging anatomies due to the development of lower-profile devices, expandable sheaths, and other innovative techniques such as intravascular lithotripsy. 4,5 Despite increased operator experience and better devices, vascular complications are still frequent after TAVR. Data from a multicenter registry reported a general incidence of major and minor vascular complications of 14.2% and 13.9%, respectively, according to the Valve Academic Research Consortium definitions, with the vast majority of them occurring after large-bore vascular closure device (VCD) failure.…”

“… 2 , 3 Transfemoral vascular access is the default strategy for TAVR, and it is currently expanding toward more challenging anatomies due to the development of lower‐profile devices, expandable sheaths, and other innovative techniques such as intravascular lithotripsy. 4 , 5 …”