Transcatheter aortic valve implantation through a diseased left common carotid artery: Combined approach with endarterectomy and left carotid‐subclavian bypass

Abstract

We report a case of transcatheter aortic valve implantation (TAVI) with the self-expanding Medtronic CoreValve bioprosthesis (Medtronic, Minneapolis, MI) through a diseased left common carotid (LCC) artery. This 81-year-old male patient presented with heart failure due to a severe degenerative aortic valve stenosis. Comorbidities included diabetes, hypertension, and dyslipidemia as well as peripheral and coronary artery disease, resulting in a logistic EuroScore II of 25.9%. Consequently, he was rejected to undergo surgery and a transcatheter approach was planned. Due to severe peripheral vascular disease with iliofemoral lesions, significant calcifications and unfavourable angulations of the innominate artery as well as prior bypass surgery precluding a direct aortic and subclavian approach, none of the established access sites were suitable. Therefore, we considered a left carotid access, which had to be combined with a surgical endarterectomy for treatment of a significant common carotid bifurcation stenosis and left subclavian-LCC permanent tunnel bypass graft. The procedure was successful without cardiac, cerebrovascular, or access complications. This case illustrates a true heart team approach, establishing a unique access for TAVI for patients without regular access options.

Transcatheter aortic valve implantation using the left transcarotid approach in patients with previous ipsilateral carotid endarterectomy

“…Even the complications rate is comparable to that of previous transcarotid reports . In particular we did not experience any vascular injuries at the left carotid access site, as reported by other authors . The surgical dissection of the left common carotid artery is easy, even in the presence of previous postsurgical adherences, and the management of bleeding or other vascular access‐site complications could be easily performed under direct control.…”

“…The authors utilized a passive antegrade carotid perfusion through a temporary carotid shunt in those patients who could not tolerate transient common carotid artery cross‐clamping test. In addition, others recommended using of passive antegrade carotid perfusion in combination with bilateral cerebral oximetry to reduce the risk of neurologic complications or a surgical bypass between the left sublavian artery and the left common carotid artery proximal to the sheath access site .…”

“…In term of vascular access‐site complications rate, the encouraging results of reports published by now and the possibility to perform TAVI through the transcarotid approach under local anaesthesia act against the drawback of a small, latero‐cervical surgical incision. Taken together, these data suggest that the transcarotid approach should become the second option of choice in the majority of centres performing TAVI in a routine manner when the transfemoral access route is not feasible.…”

Transcatheter Aortic Valve Implantation Despite Challenging Vascular Access

“…At the time of this patient's procedure, transapical access was not available in the United States, and the evidence supporting transcarotid delivery is anecdotal and controversial. 7 We considered using the transaortic approach 8 via a limited mini-sternotomy; however, this route was less appealing because of the patient's 3 venous grafts (only 2 of which were still patent), a patent left internal mammary artery (LIMA)-to-left anterior descending coronary artery graft proximal to the sternum, and tissues weakened by the patient's previous radiation therapy.…”

Transcatheter Aortic Valve Implantation by Retroperitoneal Access without General Anaesthesia

“…Since 2002 Transcatheter Aortic Valve Implantation (TAVI) has been used in patients, where frailty or concomitant diseases result in too high surgical risk for open heart surgery. With the currently available TAVI devices most patients can be treated from a technical standpoint using femoral, subclavian, apical or direct aortic access or rarely, carotid or iliac access [1][2][3]. In our first more than 200 cases, prohibitive access problems had not been an issue for denial of a TAVI procedure, but such a case was then encountered, and a solution with TAVI under full consciousness via a retroperitoneal access was finally used [4].…”