Minimum-incision transsubclavian transcatheter aortic valve replacement with balloon-expandable valve for dialysis patients.

BACKGROUND: Dialysis patients undergoing transcatheter aortic valve replacement (TAVR) face increased risk and have poorer outcomes than non-dialysis patients. Moreover, TAVR in dialysis patients using an alternative approach is considered extremely risky and little is known about the outcomes. We routinely perform minimum-incision transsubclavian TAVR (MITS-TAVR), which is contraindicated for transfemoral (TF) TAVR. This study aimed to evaluate the outcomes of MITS-TAVR compared with those of TF-TAVR in dialysis patients. METHODS: This single-center, observational study included 79 consecutive dialysis patients who underwent MITS-TAVR (MITS group, n = 22) or TF-TAVR (TF group, n = 57) under regional anesthesia. RESULTS: The rates of peripheral artery disease (MITS vs. TF, 72.7 % vs. 26.3 %; p < 0.01), shaggy aortas (MITS vs. TF, 63.6 % vs. 5.26 %; p < 0.01), and tortuous aortas (MITS vs. TF, 13.6 % vs. 1.75 %; p = 0.031) were significantly higher in the MITS group. The 30-day mortality was 2.53 % and comparable between the two groups (MITS vs. TF, 4.54 % vs. 1.75 %; p = 0.479). In the MITS group, 14 patients had ipsilateral dialysis fistulas, and three patients had patent in situ ipsilateral internal thoracic artery grafts; however, no vascular complications were observed. Kaplan-Meier survival curves for the two groups showed no significant difference in the survival rate (at 2 years; MITS vs. TF, 77.3 % vs. 68.8 %; p = 0.840) and freedom from cardiovascular mortality (at 2 years; MITS vs. TF, 90.9 % vs. 96.5 %; p = 0.898). The multivariable Cox proportional hazard model also indicated that survival in the MITS group was not significantly different from that in the TF group (hazard ratio 1.48; 95 % confidence interval, 0.77-2.85, p = 0.244). The patency rate of ipsilateral dialysis fistula was 100 % during follow-up. CONCLUSION: The outcome of MITS-TAVR was comparable to that of TF-TAVR in dialysis patients, despite the higher risk of patient characteristics.

Increased Left Ventricular End-Diastolic Volume Index Is Associated With Increased Adverse Events After MitraClip Implantation.

This study investigated the association between the left ventricular end-diastolic volume index (LVEDVI) and the incidence of adverse clinical events in patients after MitraClip implantation. In this retrospective, observational study, 123 patients who underwent the MitraClip procedure were enrolled. Participants were divided into 2 groups according to the LVEDVI cut-off level, calculated using receiver operating characteristic curve analysis, to predict the primary end point and the occurrence of cardiovascular events was compared between the groups. The primary end point was all-cause mortality and hospitalization because of heart failure. The receiver operating characteristic curve analysis for the composite primary end point revealed an LVEDVI cut-off point of 118 ml/m2. Based on this threshold, 61 patients (49.6%) were categorized into the LVEDVI <118 ml/m2 group, whereas 62 (50.4%) fell into the LVEDVI ≥118 ml/m2 group. Over a median follow-up period of 336 days (interquartile range 80 to 667), the primary end points occurred in 15 and 26 patients in the LVEDVI <118 and LVEDVI ≥118 ml/m2 groups, corresponding to incidence rates of 24.6% and 41.9%, respectively. Patients in the LVEDVI ≥118 ml/m2 group demonstrated a significantly higher risk of adverse clinical events than those in the LVEDVI <118 ml/m2 group (hazard ratio 2.24, 95% confidence interval 1.17 to 4.28, p = 0.01). This trend persisted even after adjusting for several confounders (p = 0.02). In conclusion, increased LVEDVI values were associated with increased adverse clinical events after MitraClip implantation in patients with severe mitral valve regurgitation.

Propensity score-matched comparison of total arterial off- and on-pump coronary artery bypass with complete revascularization.

Little is known regarding the long-term (> 10 years) outcomes and risk factors of total arterial coronary artery bypass grafting (CABG). This study evaluated the long-term outcomes and risk factors for all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) following total arterial on-pump CABG (ONCAB) or off-pump CABG (OPCAB) with complete revascularization. This retrospective cohort analysis enrolled patients with stable angina who underwent total arterial CABG with complete revascularization in our institute between July 2000 and June 2019. The endpoints were all-cause mortality and MACCE incidence, including a comparison between OPCAB and ONCAB. Long-term (10-year) outcomes were analyzed using propensity score-matched pairs, and risk factors were evaluated using univariate and multivariate analyses. Overall, 401 patients who underwent primary total arterial CABG were classified into the OPCAB (n = 269) and ONCAB (n = 132) groups. Using propensity score matching (PSM), 88 patients who underwent OPCAB were matched with 88 patients who underwent ONCAB. The mean follow-up period was 7.9 ± 6.3 years. No significant difference in all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 0.53-2.04; p = 0.9138) and MACCE incidence (hazard ratio, 1.06; 95% confidence interval, 0.68-1.65; p = 0.7901) was observed between the two groups. Renal failure requiring dialysis was a significant risk factor for mortality (p < 0.0001) and MACCEs (p = 0.0003). Long-term outcomes of total arterial OPCAB and ONCAB with complete revascularization showed similar findings using PSM. Renal failure requiring dialysis was a significant risk factor for mortality and morbidity.Journal standard instruction requires an unstructured abstract; hence the headings provided in abstract were deleted. Kindly check and confirm.Thank you for your kindness.Clinical registration number 5598, Tokyo Women's Medical University Hospital.

[Emergent Transcatheter Aortic Valve Implantation for Degenerated Surgical Aortic Valve Under Local Anesthesia:Report of a Case].

An 89-year-old man who had undergone aortic valve replacement with a 21 mm Mosaic bioprosthetic valve at another hospital 14 years ago was admitted to the emergency room for a sudden respiratory distress two days prior and was diagnosed with severe aortic regurgitation( AR) caused by valve insufficiency and acute heart failure secondary to low cardiac function. Upon admission, he was found to have severe hypoxia with PaO2 of 40 mmHg range, and transcatheter aortic valve replacement (TAVI, TAV in SAV) with a 20 mm SAPIEN3 was performed under local anesthesia for fear of hypotension while under general anesthesia. After confirming that AR had completely disappeared, the patient was intubated and discharged from the operating room on a mechanical ventilator. The patient was weaned from the ventilator on the second postoperative day and was transferred to the other hospital for rehabilitation, 48 days postoperatively. Although there is no report on the comparative study of anesthesia methods for emergency transcatheter aortic valve implantation( TAVI), TAVI under regional anesthesia is minimally invasive with a lower risk for hypotension than general anesthesia. Therefore, we believe it is useful for patients with acute heart failure and hypotension. In addition, it is important to use a balloon expandable valve with excellent implantability to complete the procedure in a short time.

1-year outcomes of patients implanted with the Perceval sutureless valve: the Japanese post-marketing surveillance study.

Sutureless offers an alternative to standard valves in surgical aortic valve replacement (SAVR). We sought to confirm the efficacy and safety of the Perceval sutureless valve in Japanese patients. Prospective observational study of 204 patients who underwent SAVR with Perceval at 19 sites in Japan between March and December 2019. The primary outcomes were 30-day mortality and postoperative complications; the secondary outcome was all-cause mortality at 1 year. Efficacy outcomes were changed in New York Heart Association (NYHA) class, pressure gradients, effective orifice area (EOA), EOA indexed to body surface area (EOAi) and severity of aortic regurgitation. Mean age was 77.7 years, 62.7% were female. Procedural success rate was 99.0%. The median cross-clamp and cardiopulmonary bypass times were 68.0 and 108 min. Perceval size S and M were implanted in 95 (46.6%) and in 76 (37.3%) of patients, respectively. The 30-day and late mortality rate were 0.5% and 4.4%, while the new permanent pacemaker implantation rate was 4.4%. Mean pressure gradient was 13.0 mmHg at discharge, reaching 11.0 mmHg at 1 year; while the mean EOA was 1.5 cm2 at discharge remaining stable up to 1 year. No moderate or severe leakages were present at discharge or at 1 year. NYHA class improved by ≥ 1 level in 55.1% of the patients at discharge and in 69.4% of the patients at 1 year. 1-year outcomes of SAVR with the Perceval sutureless valve in Japanese patients were favorable. This valve offers a promising alternative to conventional biological AVR in this Japanese population.

Aligning Orifice of the Renal Artery with Fish-Mouth FIXation Technique During Endovascular Aortic Aneurysm Repair for Hostile Neck Anatomy.

Background: As the success of endovascular aortic aneurysm repair (EVAR) depends on sufficient proximal fixation of the endograft to the aortic wall, the proximal hostile neck anatomy (HNA) is the major potential treatment-limiting factor in EVAR. The Aorfix endovascular stent graft was designed to operate on highly angulated aortic necks. The Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique uniquely and accurately aligns the trough part of the proximal stent end with the orifice of the lower renal artery and is used to optimize the proximal fish-mouth design for maximum proximal seal use. Herein, we aimed to evaluate the usefulness of the AORFIX technique for EVAR in patients with HNA. Methods: Eighty-one consecutive patients who underwent EVAR with the AORFIX technique (+AORFIX technique group, n = 16) and without (standard group, n = 65) were evaluated. The HNA was defined as any of the following: neck angulation ≥60°, neck length ≤15 mm, or neck thrombus or calcification ≥50% of the circumference and conical neck. Results: Each HNA criterion was similar between the two groups. However, the average number of HNA criteria was significantly higher in the +AORFIX technique group (1.9 ± .2 vs. 1.3 ± .1; P < .01). The two groups showed 100% procedural success. The concurrent renal angioplasty and stenting rates (88% vs. 4.6%; P < .01) were significantly higher in the +AORFIX technique group. There were no 30-day deaths in either group and no in-hospital device-related events in the +AORFIX technique group. The median follow-up period was 39 months, and there was no significant between-group difference in freedom from reintervention rate (+AORFIX group vs. standard group, 100% vs. 91.0%; P = .327). Conclusion: EVAR using the AORFIX technique might be useful even in patients with more complex HNA.

Minimum-incision trans-subclavian transcatheter aortic valve replacement with regional anesthesia.

BACKGROUND: Minimum-incision trans-subclavian transcatheter aortic valve replacement (MITS-TAVR) is usually performed in patients who are contraindicated for transfemoral TAVR, under regional anesthesia (RA). This study aimed to evaluate the safety and efficacy of MITS-TAVR under RA compared to MITS-TAVR under general anesthesia (GA). METHODS: This single-center observational study included 44 consecutive patients who underwent MITS-TAVR under RA (RA group, n = 19) and GA (GA group, n = 25). RA was achieved using an ultrasound-guided nerve block. RESULTS: The rates of respiratory disease (RA vs. GA, 36.8 % vs. 4.0 %; p < 0.01) and dialysis (79.0 % vs. 0 %; p < 0.01) were significantly higher in the RA group. STS score was significantly higher in the RA group (RA vs. GA, 10.8 ±â€¯1.06 % vs. 7.87 ±â€¯0.93 %; p < 0.01). Both groups had a 100 % procedural success rate. The two groups showed comparable operation room stay times (RA vs. GA, 160 ±â€¯6.96 min vs. 148 ±â€¯5.90 min; p = 0.058). The mean rate of change in blood pressure, used as an index of hemodynamic stability, was significantly lower in the RA group (RA vs. GA, 19.0 ±â€¯3.4 % vs. 35.5 ±â€¯3.0 %; p < 0.01). No in-hospital deaths occurred in either group. One case of minor dissection occurred in the GA group (RA vs.GA, 0 % vs. 4.0 %, p = 0.378). The intensive care unit stay (RA vs. GA, 0.21 ±â€¯0.11 days vs. 1.24 ±â€¯0.10 days; p < 0.01) and hospital stay (RA vs. GA, 7.00 ±â€¯1.73 days vs. 12.2 ±â€¯1.44 days; p < 0.01) were significantly shorter in the RA group. CONCLUSIONS: MITS-TAVR under RA is safe and effective and might be a promising alternative approach. It could ensure intraoperative hemodynamic stability and shorten intensive care unit and hospital stays.

Minimally Invasive Two-Stage Procedure of Aorto-Bi-Iliac Stent-Graft Implantation Performed in a Patient with an Abdominal Aortic Aneurysm and Long-Segment Iliac Artery Occlusion: A Case Report.

BACKGROUND Patients with an abdominal aortic aneurysm and long-segment iliac artery occlusion are usually treated with aorto-uni-iliac stent-graft implantation with femoro-femoral crossover bypass. However, it is more invasive than aorto-bi-iliac stent-graft implantation and poses patency issues. Herein, we describe a minimally invasive two-stage procedure of aorto-bi-iliac stent-graft implantation following iliac artery endovascular recanalization. CASE REPORT A 76-year-old man was diagnosed with an abdominal aortic aneurysm and long-segment left iliac artery occlusion. Abdominal aortic aneurysm was diagnosed during the examination of lower back pain. There were no other symptoms, including intermittent claudication. Factoring in his frail constitution and multiple comorbidities, we decided to perform aorto-bi-iliac stent-graft implantation after iliac artery endovascular recanalization to improve the patency of the left iliac artery. Aorto-bi-iliac stent-graft implantation was performed 2 days after iliac artery endovascular recanalization to avoid distal embolization. The postoperative course and 1-year follow-up were uneventful, with computed tomography revealing no endoleak and good patency. CONCLUSIONS The stent-graft implantation used in this patient is minimally invasive and results in good patency while reducing the risk of embolization. Furthermore, the long-term outcome of aorto-bi-iliac stent-graft implantation following iliac artery endovascular recanalization is more favorable than that involving treatment with aorto-uni-iliac stent-graft implantation with femoro-femoral crossover bypass.

[Introduction and Activities of Nurse Practitioner in Japan in a University Hospital].

Nurse practitioner (NP) is widely known to be an essential position of medical team in the United States, but has not yet been established as an official qualification in Japan. NP in Japan (NP-J) is accepted instead of NP, but they are not the same. We summarized the actual activities of NP-J at our hospital and had an insight into the roles of NP-J in a university hospital and the problems of introduction of NP in the future. The benefits of working as a NP-J at a university hospital are the safe acquisition of procedures at an educational institution and the involvement of various departments. In the future, the education of NP-J in a university hospital may lead to the training of NP-J working in public and private hospitals. The problem of introduction of NP in the future is the legislation. The importance of task shifting and education of NP-J in a university hospital may lead to the spread of NP in the future in Japan.

Multibranched endovascular repair using a modified endograft with hydrogel-reinforced fenestrations.

OBJECTIVES: We devised a novel physician-modified endograft (PMEG) with hydrogel-reinforced fenestrations to provide a more secure connection with the bridging graft than fenestrations alone. We applied this novel PMEG in a clinical setting and evaluated the clinical and technical results. METHODS: In this study, patients with complex thoraco-abdominal aortic pathologies involving the renal, superior mesenteric or coeliac artery were included. However, patients with pararenal abdominal aneurysm were excluded. Regardless of anatomical suitability, all patients referred to our hospital were enrolled. All patients were treated via compassionate use of PMEG. All PMEGs were used following the same procedure using hydrogel-reinforced fenestrations. A retrospective analysis was conducted on consecutive patients who were treated between October 2018 and April 2021. RESULTS: Out of 40 patients, 29 and 11 were men and women, respectively. The median patient age was 73.6 (range: 49-87) years. Among the patients, 36 (90%) had true aneurysms, whereas the others had false lumen aneurysms and penetrating atherosclerotic ulcer. Despite anatomical challenges, all branches were successfully reconstructed. The mean operative time was 333 (standard deviation 98) min. Postoperative computed tomography angiography did not reveal type I and IIIc endoleaks from the hydrogel-reinforced fenestrations. The 30-day survival rate was 97.5%. One patient died due to brain haemorrhage on postoperative day 5. During follow-up, computed tomography revealed no migration of any bridging graft. CONCLUSIONS: We confirmed the effectiveness of the hydrogel as a sealing material and the secure connection between hydrogel-reinforced fenestrations and side branches in vivo. CLINICAL TRIAL REGISTRATION NUMBER: 5287.

Modified Candy-plug Device for Dilated False Lumen Occlusion: Is a Candle Better Than a Candy?

The AFX stent graft (Endologix) has an active seal mechanism that can conform to an irregular vascular lumen. We modified the candy-plug technique using an AFX VERA suprarenal extension with restricted purse-string sutures to shape it into a candle-like contraption. We treated 2 patients with patent, dilated false lumens (FLs) after central aortic repair using this technique. This plug was deployed into the FL to block retrograde blood flow proximally. Partial or complete thrombosis of the FL was observed in both patients 6 months after surgery. This technique was feasible for FL occlusion.

[Selective Branch Embolization and Thoracic Endovascular Aortic Repair for Asymptomatic Bronchial Artery Aneurysm:Report of a Case].

Bronchial artery aneurysm (BAA) is a rare disease, for which early treatment is recommended due to the risk of rupture often resulting in severe consequences. We report a case of successful treatment of an asymptomatic BAA by selective branch embolization combined with thoracic endovascular aortic repair (TEVAR). A 68-year-old man was accidentally found to have a bronchial artery aneurysm by computed tomography. The distance from the origin of the bronchial artery to the aneurysm was only 6 mm, at which branches were found. The BAA was completely excluded by selective branch coil embolization and deployment of a thoracic stent graft to cover the orifice of the BAA. Angiography confirmed that there was no endoleak. Selective branch embolization of BAA combined with TEVAR is effective to completely occlude the blood stream to BAA.

[Retrieval of the Ruptured Balloon during Transcatheter Aortic Valve Replacement without Complications:Report of a Case].

A 77-year-old man with a history of coronary artery bypass grafting underwent transcatheter aortic valve replacement(TAVR) via femoral artery for severe aortic stenosis(AS). Preoperative computed tomography(CT) showed there was mild calcification at the sino-tubular junction(STJ). Sapien 3 was implanted successfully, but at the end of full inflation, the balloon ruptured. The ruptured balloon was retrieved without any remnants or vascular injury. A transesophageal echocardiogram showed adequate valve deployment. TAVR with its less invasiveness has become an alternative treatment for high risk patients who cannot endure surgical aortic valve replacement(SAVR). Although there are several complications related to TAVR, they can be predicted in many cases by analysis of preoperative imaging. In this case, the rupture of the balloon was not predicted because there was no significant calcification at the STJ. Caution should be taken even though there seems to be low risk of complications by preoperative imaging modalities.

Successful transcatheter aortic valve in valve implantation for degenerated trifecta bioprosthesis in a patient with a coronary anomaly.

We report a case of transcatheter aortic valve implantation in a 79-year-old woman with a coronary anomaly who underwent surgical aortic valve replacement with a 23-mm Abbott Trifecta bioprosthesis. The procedure was performed in response to severe aortic stenosis caused by a bicuspid aortic valve. Computed tomography showed an anomalous origin of the right coronary artery from the left coronary sinus, with an interarterial course. Although the virtual transcatheter valve to coronary ostium distance-right coronary artery was short, the right coronary artery ostium was just behind the stent post. The externally mounted leaflet was unable to reach the coronary orifice beyond the stent post. This case highlights a successful transcatheter aortic valve implantation for stented bioprostheses with externally mounted leaflets when the virtual transcatheter valve to coronary ostium distance is shortened by a coronary anomaly.

Utility of the minimum-incision transsubclavian approach for transcatheter aortic valve replacement on clinical outcomes in patients with small vessel anatomy.

BACKGROUND: The optimal approach for patients undergoing transcatheter aortic valve replacement (TAVR), who are contraindicated for a transfemoral (TF) approach, is still controversial. The present study aimed to evaluate the utility of the TAVR via a subclavian artery with a small diameter, by minimal incision and a double Z suture hemostasis technique using 18 Fr DrySeal Flex sheath, namely minimum-incision transsubclavian TAVR (MITS-TAVR), in patients contraindicated for the TF approach. METHODS: We included consecutive patients who underwent the MITS-TAVR (MITS group; n = 21) and TF-TAVR (TF group; n = 81) using the CoreValve Evolut R/PRO valves and examined the incidence of in-hospital adverse events and post-discharge mortality between the two groups. RESULTS: The mean body surface area was significantly smaller in the MITS group (1.33 ± 0.04 vs. 1.43 ± 0.02 m2; p = 0.045). The minimal lumen diameter of the femoral artery was significantly smaller in the MITS group (5.01 vs. 6.43 mm; p < 0.01). The lumen diameter of the left subclavian artery (LSA) in the MITS group was 4.97 ± 0.14 mm. The duration of the TAVR procedure to discharge was not significantly different (9.7 ± 2.0 days vs. 13.2 ± 1.0 days; p = 0.239). We did not experience in-hospital death in both groups, and no significant differences were observed in the incidence of major adverse cardiac and cerebrovascular events between the two groups. The post-discharge survival rate was not significantly different between the groups (at 2-year; MITS group vs. TF group = 91.0% vs. 89.0%; p = 0.725). CONCLUSIONS: The MITS-TAVR using 18 Fr Dryseal Flex sheath was safe and effective and might be a promising alternative approach even in patients with a small body and small LSA diameter, who are contraindicated to the TF approach.

Haemodynamic collapse immediately after transcatheter aortic valve implantation due to dynamic intraventricular gradient: a case report and review of the literature.

BACKGROUND: Dynamic intraventricular obstruction after transcatheter aortic valve implantation (TAVI) has been previously reported. There is a risk of haemodynamic collapse in the case of left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion (SAM) of the mitral valve. CASE SUMMARY: An 83-year-old woman with aortic stenosis (AS) was referred to our hospital for TAVI. Transthoracic echocardiography revealed a severely calcified aortic valve with a peak velocity of 6.3 m/s across the valve. Acceleration of blood flow (peak velocity 2.6 m/s) at the LVOT due to a septal bulge was also seen. Transfemoral TAVI was performed, and a 29 mm Evolut PRO was implanted under general anaesthesia. After the implantation, a complete atrioventricular block with junctional rhythm developed, and refractory hypotension occurred immediately. Transoesophageal echocardiography revealed LVOT obstruction due to SAM of the mitral valve associated with severe mitral regurgitation (MR), which was not observed preoperatively. Fluid infusion and catecholamine administration were not effective. However, after performing temporary pacing from the right ventricular (RV) apex, the LVOT obstruction and severe MR improved. Her haemodynamics stabilized, and we could complete the procedure. A dual-chamber permanent pacemaker with beta-blocker administration as a longer-term treatment further improved the LVOT obstruction. The patient was finally discharged to a rehabilitation hospital. DISCUSSION: Alertness and recognition of potential LVOT obstruction after TAVI are important. Pacing from the RV apex, as well as dual-chamber pacing, comprise a less invasive and feasible therapeutic option in such cases.

Safety and efficacy of the percutaneous thoracic endovascular repair with regional anesthesia.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is typically performed with general anesthesia (GA) and surgical cutdown (G-TEVAR). As the latest generation of TEVAR delivery systems are smaller, we introduced percutaneous TEVAR with regional anesthesia (RA) (R-TEVAR) and an arteriotomy closure device. In this study, we compare the safety and efficacy of R-TEVAR to that of the G-TEVAR. METHODS: This single-center observational study included consecutive patients who underwent either G-TEVAR between January 2015 and October 2018 (33 patients) or R-TEVAR (41 patients) between January 2018 and April 2020. RA was achieved using an ultrasound-guided nerve block. RESULTS: The mean outer diameter of the delivery device was significantly smaller in R-TEVAR (18.5 vs. 22.7 Fr; p < 0.01) and the time from arriving into the operating room to beginning of surgery (34.1 vs. 68.5 min; p < 0.01), procedural time (46.4 vs. 103.6 min; p < 0.01), and operating room stay time (108.3 vs. 194.6 min; p < 0.01) were significantly shorter. The mean rate of change in blood pressure was significantly lower in the R-TEVAR group (7.7% vs. 32.2%; p < 0.01). One case of spinal cord ischemia occurred in the G-TEVAR group (0% vs. 3.0%; p = 0.262) and one case of inadequate hemostasis and conversion to surgical cutdown without GA occurred in the R-TEVAR group (2.4% vs. 0%; p = 0.366). CONCLUSIONS: The R-TEVAR is safe and minimally invasive. Further, RA may provide additional benefits of mean blood pressure stability and early recognition of neurologic complications.

Transcatheter aortic valve implantation after branched thoracic endovascular aortic repair in zone 0.

An 83-year-old woman who underwent emergent hemi-arch replacement for acute aortic dissection (Stanford Type A) and staged branched thoracic endovascular aortic repair in zone 0 was admitted for severe aortic stenosis. We performed transfemoral transcatheter aortic-valve implantation with an SAPIEN 3 valve. The interference between the stent frames of the valve and the stent grafts in the aortic arch was concerning. However, using the SAPIEN 3 valve's flex system, the valve was successfully delivered through the complex structure in the aortic arch without any aggravation. The patient's postoperative course was uneventful.