Snaring wire technique during transcatheter aortic valve replacement

Excerpt

An 89-year-old man was referred to our hospital for the treatment of symptomatic severe aortic stenosis. Transthoracic echocardiography revealed an aortic area of 0.7 cm² and left ventricular ejection fraction of 30%. Computed tomography showed severely calcified aortic cusps with a 75-mm annular perimeter and atherosclerotic aorta with a mural thrombus on the greater curvature of the aortic arch (Fig. 1a–c). The minimum iliac-artery lumen diameter was approximately 5.5 mm. Transfemoral transcatheter aortic valve replacement (TAVR) was conducted due to anatomical difficulties and invasiveness, causing unfavorable alternative access. Considering the bulky aortic cusps and small access diameter, we decided to use a CoreValve Evolut R valve (Medtronic, Minneapolis, MN, USA). Transesophageal echocardiography (TEE), before delivery catheter advancement across the aortic arch, showed the catheter tip passing near the thrombus (Fig. 1d). Therefore, we used a snare catheter to change the wire and delivery catheter routes to avoid the risk of thrombus detachment. A 15-mm GooseNeck snare (Microvena Corporation, White Bear Lake, MN, USA) for wire anchoring was inserted via the right brachial artery (Fig. 1e). We advanced the valve while pulling the wire via femoral access. The position of the snared wire changed from the greater to the lesser curvature (Fig. 1f, g). Thereafter, the delivery catheter was successfully advanced through the aortic arch without contact with the thrombus. Valve implantation was successfully performed; the patient recovered without thromboembolic complications.

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