Orbital atherectomy to facilitate transfemoral transcatheter aortic valve implantation in patients with calcified iliofemoral arteries: a case series

Abstract

Background The transfemoral approach drives most of the advantages of transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement (SAVR). Alternative accesses for TAVI are associated with higher complication rates, but are still considered in approx. 5% of cases due to peripheral arterial disease (PAD). Percutaneous transluminal angioplasty (PTA) can still allow transfemoral TAVI in selected cases with severe calcific PAD; however, ancillary techniques for calcium management are often needed. Case Summary Orbital atherectomy was selected to facilitate transfemoral TAVI in two patients with different degrees and aspects of calcific PAD. Pre-procedural computed tomography analysis was key to choose the most appropriate technique for calcium management. We describe our experience with a step-by-step procedural approach to orbital atherectomy-assisted transfemoral TAVI. Discussion PAD is not uncommon in patients affected by severe symptomatic aortic valve stenosis. Orbital atherectomy can still allow transfemoral TAVI in selected cases with severe calcific PAD. A meticulous patient selection and a standardized, step-wise procedural execution are mandatory to optimize outcomes.

Vascular access site complications after transfemoral transcatheter aortic valve implantation: a comparison of open and percutaneous puncture approaches

“…Additionally, operation time is longer with OP because of the time required to open and close the surgical wound ( 6 ). Other disadvantages of OP are the risks of wound infection and lymphorrhea, which may require long-term treatment such as antibiotics, debridement, or other procedures ( 3 , 6 , 7 ). No patient in our study developed a wound infection requiring debridement; only three with a wound dehiscence required re-suturing.…”

“…This site is easy to expose and puncture and access site complications are easily addressed. These complications are fairly common in patients undergoing TAVI because a large-diameter sheath is required to accommodate the implanted valve ( 3 , 4 ).…”

“…Achieving hemostasis and treating vascular injuries are easier with OP; however, OP is associated with potential wound complications, such as wound infection and lymphorrhea. Moreover, the incidence rates of bleeding complications and blood transfusion are higher with OP than PP ( 3 ). PP is associated with lower incidence of wound infection and shorter hospital length of stay but a higher incidence of femoral artery stenosis and dissection ( 5 - 7 ).…”