Crossroads: advanced guidance through an aortic coarctation by fusion imaging in transfemoral TAVR after aorto-aortic bypass

Excerpt

A 78-year-old male patient with symptomatic aortic valve stenosis and history of surgical therapy of a preductal aortic coarctation by an aorto-aortic bypass was admitted to our Heart Center (Fig. 1; A: 3D-reconstruction from CT/B: fluoroscopy/C: fusion imaging; elongated native aortic arch (a) with coarctation (arrow), and aorto-aortic bypass (b)). Echocardiography and CT scan showed a degenerated and severely calcified bicuspid aortic valve (Type I LR, according to Sievers classification [1], D). Severe annular calcification was favoring the selection of a self-expandable prosthesis. Intricacy of vascular access for transcatheter aortic valve replacement (TAVR) was relevantly increased due to the patient’s special anatomy with an intact aortic bypass graft bearing a large appositional thrombus (**, E), whereas the patent native aortic arch was stenotic and elongated in kind of a “double-z” shape with two stenotic segments (smallest vessel diameter 9 mm in a 135° curve directly distal to the ostium of the left carotid artery, see arrow in A and red color markers in C). As an alternative subclavian access was unfavorable due to angulation and vessel diameter, we decided for the “long way” in kind of transfemoral approach via the native kinked aortic arch.

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