Rescue bare-metal device placement to treat iatrogenic acute type A aortic dissection during transcatheter aortic valve replacement

Intraoperative iatrogenic ATAAD in the ascending aorta during CoreValve TAVR.

Central Message.

Endovascular techniques were used to treat intraoperative iatrogenic ATAAD during CoreValve TAVR.

Acute type A aortic dissection (ATAAD) during transcatheter aortic valve replacement (TAVR) is a rare but life-threatening complication. We report a case of intraoperative iatrogenic ATAAD in an 81-year-old woman undergoing a TAVR recapture. A bare-metal dissection stent (BMDS) was placed, producing a successful outcome. The institutional review board approved this work (no. H-18095; approved February 21, 2006). An ethics review was completed, and written informed consent was obtained from the patient to publish her data.

Case Presentation

An 81-year-old woman of the Jehovah's Witness faith presented to our institution for evaluation and treatment of symptomatic severe aortic stenosis. Her medical history included declining functional capacity, dyspnea on exertion, atrial fibrillation, pulmonary hypertension attributable to interstitial lung disease, rheumatoid arthritis, and Sjogren syndrome. She was undergoing long-term immunosuppression therapy with methotrexate and golimumab. Her aortic root (26 mm) and ascending aorta (25 mm) were within a normal diameter range, per imaging studies 5 weeks earlier. Transthoracic echocardiography revealed a left ventricular ejection fraction of 60% to 64%, normal wall motion, aortic valve area of 0.5 cm², mean gradient of 29.9 mm Hg, and peak velocity of 4.0 m/s—findings consistent with severe aortic valve stenosis. Given her direct refusal of blood products, multiple comorbidities, and immunosuppressive-related concerns about healing, elective TAVR was planned.

The aortic annulus was sized using computed tomographic angiography (CTA); the major and minor diameters were 22 mm and 19 mm, the perimeter was 64 mm, and the cross-sectional area was 322 cm². Manufacturer sizing guidelines indicated that both 23- and 26-mm CoreValve Evolut PRO valves (Medtronic) were acceptable. To maximize effective orifice area, we initially attempted to implant a larger, 26-mm CoreValve transfemorally. However, displacements in the aortic annulus prevented successful valve deployment, necessitating recapture. The valve was deemed oversized, so a 23-mm CoreValve was deployed.

Postoperatively, the patient's hemodynamics were stable, and transthoracic echocardiography showed the valve in a good position with no paravalvular leak or gradient across the valve. Angiography revealed DeBakey type II dissection of the greater curvature of the ascending aorta, extending from the CoreValve's midframe to the innominate artery (Figure 1), but without retrograde extension into the sinuses or any involvement of the coronary arteries, which were well visualized. The dissection flap was dynamic, compressing the true lumen; however, no entry tear was clearly identified. To stabilize the dissection flap, expand the true lumen, and mitigate possible progression of DeBakey type II dissection to type I dissection, the Cook Zenith Dissection Endovascular System was used to advance and deploy a 36 × 80-mm BMDS (the smaller of this system's 2 options) within the upper portion of the CoreValve frame, extending coverage to the base of the innominate artery (Figure 2). Final intraoperative CTA and intravascular ultrasonography documented good apposition, flap stability, and normal TAVR valve function; these findings were confirmed by CTA on postoperative day 1.

Figure 1.

Angiogram after initial transcatheter aortic valve replacement (TAVR), revealing dissection (white arrowheads) in the ascending aorta extending from the CoreValve midframe to the innominate artery.

Figure 2.

Final angiogram. Although blood flow persists in the false lumen, good blood flow is visible in the true lumen. The aortic dissection shows no proximal extension, and the innominate artery remains perfused. Although the great vessels were covered during repair, the device's bare framework did not hinder blood flow.

The patient's postoperative course was complicated by complete atrioventricular block that necessitated dual-chamber pacemaker placement but was otherwise uneventful. The patient was discharged home on postoperative day 7 and remained well at 4-year follow-up.

Discussion

ATAAD during TAVR is a rare but life-threatening complication. Ashwat and colleagues¹ reported an incidence of 0.14% in 4317 patients who underwent TAVR; ATAAD was associated with a high early mortality rate, underscoring the seriousness of this event.² In our case, the dissection probably occurred during valve repositioning, a known risk during manipulation of self-expanding devices such as the CoreValve Evolute. Although the device allows recapture and repositioning, this maneuver can increase shear stress on the aortic wall, potentially leading to aortic wall tears.

Treatments for iatrogenic ATAAD include open TAVR device explant and aortic valve replacement along with ascending-to-hemiarch aortic replacement under hypothermic circulatory arrest. Nienaber and colleagues³ discussed the expanding role of thoracic endovascular aortic repair in proximal dissections, although they emphasized the need for careful patient selection and anatomical suitability. Our strategy aimed to stabilize the dissection flap and restore true-lumen perfusion without open surgery. Wamala and colleagues⁴ reported successfully deploying an uncovered stent within a short, fabric-covered stent graft to enhance stability during endovascular repair in a nonagenarian with ATAAD, highlighting this technique's potential in select patients.

Despite its promising outcomes, BMDS placement in the ascending aorta remains off-label, and potential indications for use remain unclear. Long-term durability data are lacking, and careful follow-up is needed. Nevertheless, this case adds to the growing body of evidence that endovascular repair could be a life-saving option for select patients with ATAAD who are not candidates for open surgery. Future studies should focus on refining patient-selection criteria and improving device design for the ascending aorta.

Conflict of Interest Statement

Dr Moon serves on an advisory board for Edwards Lifesciences. Dr Coselli consults for and participates in clinical trials for Terumo Aortic, Medtronic, Inc, and W. L. Gore & Associates; and participates in clinical trials for Abbott Laboratories, Artivion, AstraZenica, and Edwards Lifesciences. Dr Orozco-Sevilla participates in clinical trials for Gore Medical, Cook Medical, and Terumo Aortic. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.