Simultaneous transcatheter aortic valve implantation and endovascular aneurysm repair in a patient with very severe aortic stenosis with abdominal aortic aneurysm

Abstract

The safety of non-cardiac surgery is uncertain for asymptomatic patients with very severe aortic stenosis (AS). Herein, we describe a case involving an elderly and frail patient with asymptomatic, very severe AS. The patient was considered a high-risk candidate for aortic valve replacement (AVR); thus, transcatheter aortic valve implantation (TAVI) was planned. On perioperative examination, an abdominal aortic aneurysm (AAA) was observed, which required endovascular aneurysm repair (EVAR). To reduce the risks involved with sequential procedures, TAVI and EVAR were performed simultaneously. In patients with severe AS who are high-risk candidates for AVR, TAVI can be considered as an alternative therapy before non-cardiac surgery. In addition, the combined TAVI and EVAR procedure can reduce the risks associated with the perioperative period.

<Learning objective: For patients with severe aortic stenosis who are high-risk candidates for aortic valve replacement (e.g. elderly patients with comorbidities), transcatheter aortic valve implantation (TAVI) can be considered as an alternative therapy before non-cardiac surgery. In addition, combining TAVI and endovascular aneurysm repair can reduce the perioperative risks compared with those for sequential procedures. However, additional research is needed.>

Introduction

Severe aortic stenosis (AS) is a risk factor for non-cardiac surgery [1], [2]. According to the European Society of Cardiology (ESC) guidelines, non-cardiac surgery of low-to-intermediate risk can be safely performed in asymptomatic patients with severe AS [1]. However, the safety of non-cardiac surgery is uncertain for asymptomatic patients with very severe AS; thus, aortic valve replacement (AVR) may be considered before non-cardiac surgery. In patients for whom AVR is considered a high-risk procedure, transcatheter aortic valve implantation (TAVI) can be a reasonable therapeutic option [1], [2]. Herein, we describe a case involving an elderly, frail patient with asymptomatic very severe AS and an abdominal aortic aneurysm (AAA) who underwent TAVI and endovascular aneurysm repair (EVAR) simultaneously.

Case report

An 83-year-old man underwent transthoracic echocardiography because of an incidental systolic cardiac murmur. The patient was diagnosed as having very severe AS, as defined by a maximum flow velocity of over 5.5 m/sec [3]. His valve leaflet morphology was bicuspid, the maximal velocity of the aortic valve (AV) was 6.3 m/sec, and the mean pressure gradient of the AV was 105 mmHg. Even when asymptomatic, depending on the situation, AVR is recommended for patients with very severe AS given their poor prognosis and high adverse event rate [3], [4]; these disadvantages can be ameliorated by early surgical intervention. Although the patient wished to undergo invasive treatment, AVR was considered a high-risk treatment because of his frailty (Clinical frailty scale stage 5) [5]. In addition, he was complicated with pancytopenia due to myelodysplastic syndrome. Therefore, TAVI was considered as an alternative therapy.

Based on a preoperative computed tomography (CT) scan, the patient was diagnosed as having an AAA (diameter, 57 mm; Fig. 1), which required treatment with stent-graft. As preceding TAVI before EVAR can increase the risk of AAA rupture due to post procedural hypertension [6], we decided to perform TAVI and EVAR simultaneously.

Fig. 1.

A cross-sectional computed tomography image showing an abdominal aortic aneurysm (AAA) with a diameter of 57 mm. AAA ranged from just beneath the branch of the renal artery to the proximal part of the common iliac artery on both sides.

A surgical cut-down was performed on the left femoral artery, and an 18-French sheath was inserted into the left femoral artery. Balloon aortic valvuloplasty was performed under controlled pacing using a 15-mm balloon. A 26-mm CoreValve (Medtronic, St Paul, MN, USA) was determined suitable based on the preoperative CT scan, and it was placed under fluoroscopic and transesophageal echocardiography guidance (Fig. 2). After TAVI, EVAR was performed using the same access site as that used for TAVI. A 26 mm–14.5 mm–18 cm trunk-ipsilateral leg (W.L. Gore & Associates, Flagstaff, AZ, USA) was delivered from an 18-French sheath that was inserted in the left femoral artery and placed from the aorta directly beneath the branch of the renal artery to the left common iliac artery. Subsequently, the 6-French sheath that was inserted in the right femoral artery was exchanged with a 12-French sheath. Meanwhile, a 16 mm–18 mm–13.5 cm contralateral leg (W.L. Gore & Associates) was placed from the trunk-ipsilateral leg to the right common iliac artery. We performed post dilatation with a 32-mm diameter Coda aortic balloon (Cook Incorporated, Bloomington, IN, USA). The procedure was completed without complication with an excellent final angiographic image (Fig. 3). The total procedure time was 138 min, the total fluoroscopic time was 52.6 min, and the amount of contrast medium used was 182 mL. The patient was discharged 8 days postoperatively without any complications.

Fig. 2.

Valve implantation. A 26 mm CoreValve was placed in the appropriate location.

Fig. 3.

Angiograms of the abdominal aortic aneurysm pre- and post-endovascular aneurysm repair. An excellent final angiographic image, which did not exhibit endoleak, was obtained.

Discussion

Severe AS is a risk factor for non-cardiac surgery, as surgical stress and anesthesia can precipitate impaired hemodynamic status. Furthermore, perioperative hypotension and tachycardia can cause arrhythmia and myocardial ischemia, which may lead to myocardial injury and death [1], [2].

The current patient was complicated with very severe AS and AAA. According to the ESC guidelines, non-cardiac surgery of low-to-intermediate risk can be performed safely in patients with asymptomatic severe AS [1], [3]. In addition, EVAR is associated with a lower operative risk compared to open surgery [7], and it is classified as an intermediate-risk surgery in the ESC guidelines, which can be performed safely in asymptomatic patients with severe AS. However, it has not been fully elucidated whether non-cardiac surgery with intermediate risk can be performed safely in patients with asymptomatic very severe AS; such patients may not be able to tolerate hemodynamic stress during non-cardiac surgery [4].

AVR before non-cardiac surgery may be considered when non-cardiac surgery under severe AS is regarded as high risk. In the current case, AVR was deemed a high-risk procedure because of the patient’s frailty and myelodysplastic syndrome-related pancytopenia. For high-risk patients, TAVI can be a therapeutic option [1], [2]. Although the efficacy and safety of TAVI in patients with AS undergoing non-cardiac surgery are uncertain, several case series have reported the usefulness of sequential or combined TAVI and EVAR [8].

Although the patient’s valve morphology was bicuspid, we decided to perform TAVI and use the CoreValve. First, the TAVI for bicuspid AV can result in elliptical deployment, accelerated leaflet degeneration, periprosthetic leaks, and aortic complications. Meanwhile, multiple reports have documented the safety and efficacy of TAVI for bicuspid AV [9]. Second, at the time of patient treatment, the CoreValve was the only device approved in Japan for TAVI in patients with a bicuspid AV. According to the expert’s opinion, in the case of a bicuspid AV, the reference perimeter which determined the size of valve is usually measured 5–8 mm superior to the basilar annular plane. This patient’s perimeter ranges from 67 to 74 mm, which was within the upper range of a 26 mm and the lower range of a 29 mm valve. Since there was the large calcified nodule in the valve complex, we selected a 26 mm CoreValve to avoid the risk of aortic rupture.

The combined TAVI and EVAR procedure has the following advantages over performing the procedure sequentially. First, the combined procedure can reduce the risk of AAA rupture. It is reported that systemic blood pressure rises after removing the pressure gradient of the AV [6]. With the procedures performed sequentially, the AAA may be exposed to elevated blood pressure after TAVI, increasing the risk of AAA rupture. Second, it can minimize invasiveness and perioperative complication risks. Using the same vascular access site can reduce the risk of vascular complications, including bleeding and wounding. Such complications are common after EVAR and occur in 8% of patients [7]. Conversely, the occurrence of major vascular complications and life-threatening or disabling bleeding events in the CoreValve US pivotal trial were 5.9% and 13.6%, respectively [10]. These incidences can be reduced by performing the combined procedure, which also avoids the repeated use of general anesthesia. The third advantage is the shortening of the length of hospitalization, which is meaningful for elderly patients with several comorbidities (i.e. patients requiring TAVI).

We performed TAVI, not EVAR, first. We deem that it is safe to perform non-cardiac surgery after stabilizing the hemodynamic status of the patient. In our case, the AS was very severe (i.e. maximum flow velocity was 6.3 m/sec), and it is unclear whether non-cardiac surgery with intermediate risk can be performed safely in asymptomatic patients with very severe AS. Indeed, such patients may not be able to tolerate hemodynamic stress during non-cardiac surgery. If we were to perform EVAR first and collapse occurred, recovery from cardiogenic shock would likely have been difficult due to very severe AS. The first TAVI approach can increase the risk of AAA rupture, distal embolism, and aortic dissection, since this procedure requires passage of TAVI devices through the AAA. Fortunately, the sheath length (32 cm) was enough to cross over the AAA in the current patient, and there was little risk of an AAA rupture and injury.

In conclusion, a patient with very severe AS and AAA was successfully treated with combined TAVI and EVAR. For patients with severe AS who are high-risk candidates for AVR, TAVI can be considered as an alternative therapy before non-cardiac surgery. In addition, the combined procedure can reduce the risks associated with the perioperative period.

Conflicts of interest

The authors declare that there are no conflicts of interest.