Modified TA-TAVI for Patients with Zero Transvascular Options: Novelty!

Background: Meanwhile it is clear that there are TAVI candidates with clinical characteristics who cannot undergo or who are at high interventional risk for TF-TAVI. Therefore, other alternative transvascular approaches, such as transcarotid or transsubclavian have been studied and preferred for this specific TAVI population. However, there are some TAVI candidates with severe panarteriopathy (femoral and femoral-remote arteriopathy) who cannot undergo any transvascular approach. This subgroup has been not studied so far. We aimed to develop a new method modifying the TA-TAVI method to ensure artery-no-touch technique for patients without any arterial access.

Method: Femoral vein wire at the beginning of the procedure to serve as a “safety net.” To minimize apex trauma a soft guidewire was inserted antegrade across the stenotic aortic and was not followed by insertion of a 14-Fr soft-tip sheath for positioning of a stiff guidewire. Instead, we used a 6-Fr sheath. We did not insert any artery wire for “safety net” and visualization with the mean of pigtail. This was performed through the left ventricle wall, beside the valve delivery sheath through a 6-Fr sheath and the pigtail was introduced into the ascending aorta. Before completing the valve-expansion we put it back into the left ventricle, and after valve expansion again into the ascending aorta through valve prosthesis for quality control. For eventual bailout strategy the inserted 6-Fr sheath through the left ventricle wall should serve as a ductus for an eventual insertion of an aortic cannula through the left ventricle wall and through the aortic valve for eventual need of cardiopulmonary bypass.

Results: Six high-risk elderly patients underwent this method between 2017 and 2021 at our institution. These candidates failed in the heart team to be surgical or TF-TAVI candidates. Baseline characteristics were significant for severe PAD, porcelain aorta, aortic thrombus, aortic pseudoaneurysm, Leriche syndrome, subclavian artery occlusion, A-V shunt for dialysis, previous coronary bypass using LIMA graft, previous carotid thromboendarterectomy with patch plasty on both sides. No procedural complications and no in-hospital mortality or stroke were registered.

Conclusion: Modified, artery-no-touch TA-TAVI is safe and feasible in selected patients who cannot undergo transvascular approaches.

Publication History

Article published online:
28 January 2023