This report describes the complexity of transcatheter aortic valve replacement in which rare complications sometimes occur, even at experienced centers. This is a case of cranial migration of an infrarenal aortic aneurysm endograft while advancing the balloon-expandable prosthesis through the infrarenal aorta, which was subsequently successfully treated by deploying a thoracic endoprosthesis after deployment of the aortic valve bioprosthesis.
The transcatheter aortic valve replacement (TAVR) procedure is a well-established treatment for aortic valve stenosis and has evolved into a minimally invasive, relatively low-risk procedure in most patients. Device dislocation or embolization during TAVR is rare but can lead to life-threatening complications.1 Once complications occur, they are best managed using a multidisciplinary approach incorporating both percutaneous and surgical techniques. This report describes a challenging case of dislocation of an aortic endoprosthesis (infrarenal endovascular aneurysm repair [EVAR]) during a TAVR procedure that was subsequently treated percutaneously.
An 84-year-old man with a history of EVAR with GORE C3 28-mm × 14-mm × 18-mm Excluder AAA prosthesis and extender 28-mm × 3.3-cm endoprosthesis placed proximally for type 1 endoleak (Fig. 1) and severe, symptomatic aortic valve stenosis was referred to the hospital for management of valvular disease. After evaluation, the heart team elected for a transfemoral TAVR under moderate sedation with a 23-mm SAPIEN 3 prosthesis (Edwards Lifesciences). Bilateral access was obtained using ultrasound guidance. A 14F Edwards sheath was placed in the right common femoral artery and advanced under fluoroscopic guidance, with the tip landing just proximal to the abdominal aortic graft. Standard procedural techniques followed until physicians noted resistance with advancement of the 23-mm valve out of the sheath. The valve was advanced over a Safari wire using a Commander delivery system (Edwards Lifesciences). Upon entry into the abdominal aorta, it was noted that the extension graft had migrated with the tip of the Commander system. Physicians attempted to slide the valve through the extension graft, but this only resulted in further migration of the cuff into the descending thoracic aorta (Fig. 2). A goose neck snare was used in hope of stabilizing the endograft, but physicians were unsuccessful in snaring the prosthesis. Then, through the left femoral access, a wire was placed across the cuff extension and a 20-mm Tyshak balloon (BVM Medical) was advanced proximal to the endograft and inflated to pin the endograft in place. Using the flex feature of the valve delivery system, physicians deflated the trapping balloon and advanced the valve through the extension graft without further cuff migration (Fig. 3). The valve was then successfully deployed using standard techniques. The delivery device was removed, and postdeployment imaging confirmed a favorable result (Fig. 4). At this stage, there was no thoracic or abdominal aortic dissection and the migrated endograft was in stable position. Vascular surgery clinicians were called to assist, and the 14F sheath was replaced with a 22F sheath, which was advanced under fluoroscopic guidance through the dislodged proximal cuff in the descending thoracic aorta. Through this sheath, a 31-mm × 31-mm × 10-cm length thoracic GORE TAG endoprosthesis (Fig. 5) was advanced and positioned within the dislodged cuff. The graft was deployed and an aortogram showed a widely patent thoracic stent graft and no aortic wall damage (Fig. 6); however, both renal arteries were noted to be stenosed with thrombus (Fig. 7). With a therapeutic activated clotting time of 280 seconds, chronic thrombus had likely migrated from behind the cuff during dislodgment. Both renal arteries were then stented with Viabahn heparin-bonded covered stents with brisk flow in the right renal artery and good perfusion of the inferior pole of the left kidney (Fig. 8). The patient had acute kidney injury postprocedure, with a rise in creatinine from a baseline level of 1.4 mg/dL to 3.5 mg/dL. Urine output was good, and the patient did not require further intervention. At 6-month follow-up, the patient was doing well, with resolution of the severe, symptomatic aortic stenosis, and maintenance of adequate renal function with a new baseline creatinine level of 2.9 mg/dL.
This was a challenging case of dislocation of an aortic endoprostheses (EVAR) during a TAVR procedure with percutaneous management. During catheter exchange, after crossing the aortic valve and before advancing the SAPIEN valve, the Edwards sheath likely migrated below the aortic endograft and the Commander delivery system caught the edge of aortic prosthesis, leading to dislocation of the endograft during advancement of the system. Device dislocations during TAVR are rare but can lead to catastrophic consequences. Once they occur, these dislocations are best managed using a multidisciplinary approach that incorporates both percutaneous and surgical techniques.
Clinicians initially tried to use a goose neck snare to stabilize the dislocated prosthesis but were unable to capture the cuff. Then the “balloon-and-anchor” technique was used, where the stent graft was anchored using a balloon catheter inserted over a guide wire and positioned above the upper end of the prosthesis. This enabled physicians to advance the valve through the aortic cuff and eventually deploy it successfully. The migrated proximal cuff was treated with a thoracic endograft by the vascular surgery team. Thrombotic occlusion of the renal arteries resulting from stent dislodgment was treated with covered stents, leading to restoration of renal perfusion. Repositioning intraluminal maneuvers have been described and have been successful for malpositioned or dislocated aortic endoprostheses, as demonstrated in this case.1,2 Bailout options in such cases consist of emergent surgery if percutaneous maneuvers fail or extensive aortic wall damage is noticed. Retrospectively, such complications can be avoided by carefully moving the sheath or catheters under direct fluoroscopy while advancing through EVAR, ensuring that the tip is free.
The TAVR procedure is a well-established treatment for aortic valve stenosis that has evolved into a minimally invasive, relatively low-risk procedure in most patients. This case report, however, underlines the complexity of the procedure and potential for complications. Collaboration with vascular surgery colleagues is paramount in delivering optimal care.
The authors thank Dr Achal Sahai for his assistance in writing and reviewing the manuscript.
Conflict of Interest Disclosures: The authors report no conflicts of interest.