Hemodynamic outcomes after valve-in-valve transcatheter aortic valve replacement: a single-center experience.

BACKGROUND: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a safe, effective alternative to redo aortic valve surgery in high-risk patients with degenerated surgical bioprosthetic valves. However, ViV-TAVR has been associated high postprocedural valvular gradients, compared with TAVR for native-valve aortic stenosis. METHODS: We performed a retrospective study of all patients who underwent ViV-TAVR for a degenerated aortic valve bioprosthesis between January 1, 2013 and March 31, 2019 at our center. The primary outcome was postprocedural mean aortic valve gradient. Outcomes were compared across surgical valve type (stented versus stentless), surgical valve internal diameter (≤19 versus >19 mm), and transcatheter aortic valve type (self-expanding vs. balloon-expandable). RESULTS: Overall, 89 patients underwent ViV-TAVR. Mean age was 69.0±12.6 years, 61% were male, and median Society of Thoracic Surgeons Predicted Risk of Mortality score was 5.4 [interquartile range, 3.2-8.5]. Bioprosthesis mode of failure was stenotic (58% of patients), regurgitant (24%), or mixed (18%). The surgical valve was stented in 75% of patients and stentless in 25%. The surgical valve's internal diameter was ≤19 mm in 45% of cases. A balloon-expandable transcatheter valve was used in 53% of procedures. Baseline aortic valve area and mean gradients were 0.87±0.31 cm2 and 36±18 mmHg, respectively. These improved after ViV-TAVR to 1.38±0.55 cm2 and 18±11 mmHg at a median outpatient follow-up of 331 [67-394] days. Higher postprocedural mean gradients were associated with surgical valves having an internal diameter ≤19 mm (24±13 versus 16±8, P=0.002) and with stented surgical valves (22±11 versus 12±6, P<0.001). CONCLUSIONS: ViV-TAVR is an effective option for treating degenerated surgical aortic bioprostheses, with acceptable hemodynamic outcomes. Small surgical valves and stented surgical valves are associated with higher postprocedural gradients.

Transcatheter valve-in-valve implantation for degenerated stentless aortic bioroots.

BACKGROUND: Open surgical repair of a failed valve-sparing aortic root replacement (VSARR) or stentless bioroot aortic root replacement (bio-ARR) entails significant operative risks. Whether valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is feasible in patients with a previous VSARR or stentless bio-ARR remains unclear, given lingering concerns about the ill-defined aortic annulus in these patients and the potential for coronary obstruction. We present our experience with patients who had a previous VSARR or stentless bio-ARR and underwent ViV-TAVR to repair a degenerated aortic valve with combined valvular disease, aortic insufficiency and aortic stenosis. METHODS: In this retrospective data review, we identified and analyzed consecutive patients with a previous VSARR or stentless bio-ARR who underwent ViV-TAVR between December 1, 2014 and August 31, 2019. RESULTS: ViV-TAVR was performed in twelve high-risk patients with previous VSARR or bio-ARR during the study period. Of these, seven received Medtronic Freestyle porcine stentless bioprosthetic aortic roots, three received homograft aortic roots, one underwent a Ross procedure and one underwent VSARR. ViV-TAVR restored satisfactory valve function in all patients, and technical success was 100%. No patient had more than mild regurgitation after implantation. No thirty-day mortality was seen. One patient had major bleeding after transapical access, one patient had a transient ischemic stroke, and one patient needed permanent pacemaker implantation. At a median last follow-up of 21.5 months (interquartile range, 9.0-69.0 months), all patients remained alive and had satisfactory valve function. CONCLUSIONS: In this study, ViV-TAVR was a clinically effective option for treating patients with a failed stentless bio-ARR or previous VSARR. Short-term and intermediate-term results after these procedures were favorable. These findings may have important implications for treating high-risk patients with structural aortic root deterioration and call for better transcatheter heart valves that are suitable for treating aortic insufficiency.

"Simple" Transcatheter Aortic Valve Replacement With Conscious Sedation: Safety and Effectiveness in Real-World Practice.

Transcatheter aortic valve replacement (TAVR) is a well-established alternative to open surgical replacement. Strictly selecting low-risk patients and using conscious sedation during TAVR has enabled hospital stays to be safely shortened. We evaluated the safety and effectiveness of a less rigorous patient-selection process involving multidisciplinary case discussions, percutaneous procedures with the use of conscious sedation, and postprocedural care outside an intensive care unit, with the goal of discharging patients from the hospital early. We call this "simple TAVR." We retrospectively reviewed the records of patients who underwent TAVR from March 2015 through February 2020 at our center. The procedures were performed by 2 high-volume operators. Of 524 total procedures, 344 (65.6%) qualified as simple TAVR. All 344 procedures were successful. The highest 30-day complication rate was associated with new permanent pacemaker implantation (7.3%, 25 patients); the rates of major vascular complications, stroke, and all-cause death were less than 3% each. Of note, 252 patients (73.3%) were discharged from the hospital the day after TAVR, and 307 (89.2%) within 48 hours. Simple TAVR is safe, economical, and feasible in real-world practice, and it does not necessitate a rigorous perioperative protocol or patient-selection process.

Transcatheter aortic valve replacement after chest radiation: A propensity-matched analysis.

BACKGROUND: Chest radiation therapy (CRT) for malignant thoracic neoplasms is associated with development of valvular heart disease years later. As previous radiation exposure can complicate surgical treatment, transcatheter aortic valve replacement (TAVR) has emerged as an alternative. However, outcomes data are lacking for TAVR patients with a history of CRT. METHODS: We conducted a retrospective study of all patients who underwent a TAVR procedure at a single institution between September 2012 and November 2018. Among 1341 total patients, 50 had previous CRT. These were propensity-matched in a 1:2 ratio to 100 patients without history of CRT. Thirty-day adverse events were analyzed with generalized estimating equation models. Overall mortality was analyzed with stratified Cox regression modelling. RESULTS: Median clinical follow-up was 24 months (interquartile range [IQR], 12-44 months). There was no difference between CRT and non-CRT patients in overall mortality (hazard ratio [HR] 0.84 [0.37-1.90], P = 0.67), 30-day mortality (HR 3.1 [0.49-20.03], P = 0.23), or 30-day readmission rate (HR 1.0 [0.43-2.31], P = 1). There were no differences in the rates of most adverse events, but patients with CRT history had higher rates of postprocedural respiratory failure (HR 3.63 [1.32-10.02], P = 0.01) and permanent pacemaker implantation (HR 2.84 [1.15-7.01], P = 0.02). CONCLUSIONS: For patients with aortic valve stenosis and previous CRT, TAVR is safe and effective, with outcomes similar to those in the general aortic stenosis population. Patients with history of CRT are more likely to have postprocedural respiratory failure and to require permanent pacemaker implantation.

Transcatheter Aortic Valve-in-Valve Replacement Instead of a 4th Sternotomy in a 21-Year-Old Woman with Aortic Homograft Failure.

Transcatheter aortic valve replacement (TAVR) is a well-established method for replacing native aortic valves; however, it was conceived for elderly patients with aortic valve stenosis, and the lack of data on long-term durability has led practitioners to restrict the use of TAVR to patients who have short life expectancies. Here, we describe the case of a 21-year-old woman who had undergone 3 previous open aortic valve replacements and who presented with symptoms of recurrent valvular failure. Transthoracic echocardiograms and computed tomographic angiograms revealed a degenerating aortic root homograft with substantial calcification, moderate-to-severe aortic valve stenosis, and severe aortic valve regurgitation. Open surgical valve replacement posed substantial risk to our patient, so we decided to perform valve-in-valve TAVR with use of the Edwards Sapien XT Transcatheter Heart Valve. The patient's pulmonary artery pressure, valvular regurgitation, and symptoms improved substantially thereafter. We found that valve-in-valve TAVR into a failing aortic root homograft was less invasive than repeat surgical valve replacement in this young patient who had congenital vascular anomalies and a complex surgical history.

Endovascular Abdominal Aortic Aneurysm Repair by Means of the Chimney Technique in a Patient with Crossed Fused Renal Ectopia.

Crossed fused renal ectopia, a congenital anomaly in 1 of 7,000 individuals, presents a challenge during endovascular treatment of abdominal aortic aneurysm. Most treatment approaches in these patients have involved open surgical repair of the aneurysm or endovascular repair with coverage of the ectopic renal artery. We present what we think is the first case of endovascular abdominal aortic aneurysm repair with use of the chimney technique (parallel stent-grafting) to preserve an ectopic renal artery, in an 88-year-old man who was at high risk for open surgery. In addition to the patient's case, we discuss the relevant medical literature.

Endovascular Treatment of Superior Vena Cava Syndrome via Balloon-in-Balloon Catheter Technique with a Palmaz Stent.

Superior vena cava syndrome is a well-known disease entity that carries substantial rates of morbidity and mortality. Although most cases of superior vena cava syndrome are secondary to a malignant process, additional causes (such as mediastinal fibrosis, pacemaker lead implantation, or central venous catheter placement) have been reported. Multiple treatment options include percutaneous transluminal angioplasty, stent implantation, thrombolysis, mechanical thrombectomy, and venous grafting. We present a case of superior vena cava syndrome in a symptomatic 30-year-old woman who obtained complete relief of obstruction and marked symptomatic improvement through venoplasty and stenting, aided by our use of a balloon-in-balloon catheter system.

Transvenous transcatheter valve-in-valve implantation after bioprosthetic tricuspid valve failure.

We describe the case of a 38-year-old man with a history of metastatic testicular cancer who had undergone multiple thoracic surgical procedures, including tricuspid valve replacement with a bioprosthetic valve as a result of tricuspid involvement of his malignancy. He presented at our outpatient cardiology clinic with worsening fatigue, shortness of breath, and peripheral edema, investigation of which revealed severe tricuspid bioprosthesis stenosis with central regurgitation. Because of the patient's medical history, he was considered to be a high-risk surgical candidate. Therefore, transcatheter tricuspid valve-in-valve implantation of a 26-mm Edwards Sapien(®) valve was attempted through a transjugular approach. The procedure restored tricuspid valvar competence and substantially improved the patient's symptoms. We discuss the technical aspects of this case and briefly review the usefulness of the valve-in-valve technique in the tricuspid position.

Spontaneous celiac artery dissection case report and literature review.

Symptomatic spontaneous celiac artery dissection is a rare condition that is being detected more often with the use of advanced imaging techniques. There is no consensus as to whether surgical or endovascular treatment is more appropriate.We describe the case of a 41-year-old hypertensive woman who presented with the sudden onset of sharp, persistent, right-upper-quadrant abdominal and epigastric pain. Magnetic resonance angiography of the abdomen revealed celiac artery dissection, with a flap compressing the lumen approximately 17 mm from the artery's origin at the aorta. Because of the patient's persistent epigastric pain, endovascular celiac artery stent implantation was performed with the use of 2 overlapping balloon-expandable stents. Twelve months after the procedure, the patient remained asymptomatic, and the stents were patent. This case and others in the medical literature suggest that endovascular treatment can be feasible in symptomatic patients with isolated spontaneous celiac artery dissection.

Fistula from right internal mammary artery to superior vena cava after use of a laser sheath to extract a pacemaker lead.

A 55-year-old woman presented with dyspnea on exertion due to a right internal mammary artery-to-superior vena cava arteriovenous fistula that occurred after pacemaker lead extraction with a laser sheath. The fistula was successfully repaired by placing a covered stent in the right internal mammary artery. In this unusual location, endovascular stenting is a reasonable alternative to coil embolization or surgical repair of an arteriovenous fistula resulting from laser lead extraction.

Long-term results of aortic banding for complex infrarenal neck anatomy and type I endoleak after endovascular abdominal aortic aneurysm repair.

For many patients with abdominal aortic aneurysm, unsuitable anatomy of the infrarenal aortic neck precludes endovascular aortic aneurysm repair or causes type I endoleak after the procedure. In an attempt to overcome these challenges, we retrospectively examined the usefulness of aortic banding as an adjunctive procedure to endovascular repair in 8 patients who had an abdominal aortic aneurysm with a complex infrarenal aortic neck. The procedures were performed with the patients under general anesthesia and involved making an 8-cm upper-midline laparotomy incision to expose the aneurysmal aorta. Three patients underwent aortic banding before endovascular repair; the other 5 underwent banding after the repair because of persistent type I endoleak. After banding, the abdominal aortic aneurysm was successfully excluded in all 8 patients. Long-term follow-up (mean, 38±20 mo) revealed no type I endoleak and no procedure-related complications. In patients who have an abdominal aortic aneurysm with complex infrarenal neck anatomy or a refractory type I endoleak, performing aortic banding as an adjunctive procedure to endovascular aortic repair appears to be a safe strategy with good long-term results.

Low-permeability Gore Excluder device versus the original in abdominal aortic aneurysm size regression.

We sought to compare the efficacy of a low-permeability version of the Gore Excluder™ device with that of the original device. We used volumetric analysis and maximum transverse diameter measurements to examine abdominal aortic aneurysm size regression after endovascular aneurysm repair.From November 2002 through April 2007, 101 patients (82% men; mean age, 71.5 ± 8.9 yr) underwent endovascular aneurysm repair with the Excluder stent-graft: 34 with the original device, and 67 with the low-permeability device. Only patients without endoleak and with preprocedural and 1- and 2-year follow-up computed tomographic scans were included. Eight patients with type II endoleak and 2 with type I endoleak were excluded. Maximum abdominal aortic aneurysm diameter and volume were measured before endovascular aneurysm repair and annually thereafter. Postprocessing, multiplanar computed tomography, and 3-dimensional reconstructions were compared with baseline measurements. Diameter and volume changes that were greater than 5 mm or that exceeded 10% were considered significant.At 12 months, the mean maximum transverse diameter had decreased by -0.16 ± 12.1 mm in recipients of the original device and by -4.8 ± 5.9 mm in recipients of the low-permeability device (P = NS). In addition, mean reduction in volume had changed by -17 ± 16 mL in original-device recipients and by -36.1 ± 37.9 mL in low-permeability device recipients (P < 0.01).One-year follow-up revealed that the low-permeability stent-graft resulted in a greater decrease in abdominal aortic aneurysm volume than did the original stent-graft.

Technical tips for endovascular treatment of abdominal aortic aneurysms with challenging infrarenal neck anatomy using the Excluder endoprosthesis.

PURPOSE: To report technical tips of endovascular aneurysm repair using Excluder endografts in patients with challenging infrarenal neck anatomy (short, angled, and/or tapered necks). TECHNIQUE: Several tips are presented to achieve effective and durable fixation and sealing of Excluder stent-grafts in abdominal aortic aneurysms (AAA) with challenging necks. The primary approach to patients with short infrarenal necks is a slow and controlled deployment combined with the bending-the-wire technique to realign the axis of the aneurysm and the axis of the neck. Severe infrarenal neck angulation is dealt with by bending the guidewire, orienting the iliac limbs of the Excluder in the anteroposterior direction, and using the slow and controlled endograft deployment technique. Other key procedural factors, such as using the percutaneous approach and local anesthetic, reorienting the stent-graft, using Excluder aortic extensions, employing the endowedge and kilt techniques, and using the appropriate C-arm angulation to adequately visualize the target landing zone, are also useful. CONCLUSION: The techniques we describe have been valuable in achieving excellent outcomes with endovascular AAA treatment using the Excluder endoprosthesis in challenging infrarenal neck anatomy. Further improvements in device design and deployment mechanism will allow better device alignment in patients with complex infrarenal neck anatomy.

Benefits of catheter thrombectomy during carotid stenting: a preliminary study.

Despite the use of distal embolic protection devices (DEPs) in carotid artery (CA) stenting, an appreciable risk of stroke exists, particularly in symptomatic patients. The mechanism of embolic events is possibly related to microembolization of atherothrombotic débris that remains or forms on the stent struts. This study evaluated the safety of using thrombus-extraction catheters in the setting of CA stenting.From August 2006 through June 2008, 43 symptomatic and asymptomatic patients with severe CA stenosis (>90%) underwent CA stenting with DEPs. After stenting and before removal of the DEP, an extraction catheter was passed through the stented segment. The extracted volume and the filtered extracted volume were visually examined for débris. The primary outcome was a composite of stroke and death at 30 days. Outcomes were compared with those in a control population of 783 patients who underwent CA stenting with a DEP, but without prophylactic thrombus aspiration. Retrospective analysis was performed on prospectively gathered data.Substantial amounts of atherothrombotic débris were extracted from the stented segment in all 43 thrombectomy patients, none of whom died or experienced periprocedural stroke. In the control group, 3.9% of patients experienced these outcomes. Differences in primary outcome did not reach statistical significance.We conclude that the prophylactic use of extraction catheters is safe and does not incur periprocedural events. The results of this preliminary study are encouraging, although larger, randomized trials (optimally using diffusion-weighted magnetic resonance imaging) are needed in order to evaluate this technique's potential benefits in reducing neurologic complications.

Endovascular exclusion of popliteal artery aneurysms with stent-grafts: a prospective single-center experience.

PURPOSE: To determine the safety and efficacy of percutaneous treatment for popliteal artery aneurysms (PAA) using self-expanding stent-grafts. METHODS: From October 2000 through September 2007, 29 patients (27 men; mean age 68+/-6 years, range 54-88) underwent endovascular exclusion of 33 PAAs. All had symptoms of claudication, and all were atherosclerotic in origin. Four patients presented with popliteal venous thrombosis. Twenty-eight of the treated PAAs had associated mural thrombus. The mean aneurysm diameter was 34.3+/-13.3 mm and the mean lesion length was 98.6+/-102.1 mm. RESULTS: All PAAs were successfully excluded from the arterial circulation using 59 stent-grafts (15 Wallgraft and 44 Viabahn). The average number of stent-grafts implanted was 1.9+/-0.4 (range 1-3); the mean length of covered vessel (per lesion) was 198.6+/-105.3 mm. There were no device-associated complications or deaths. Over an average follow-up of 35.4+/-32.1 months (range 6-120), the primary and secondary patency rates, respectively, were 93.9% and 100% at 6 months, 93.9% and 96.9% at 1 year, and 87.5% and 96.8% at 2 years. At 4.5 years, primary and secondary patency rates were 84.8% and 96.8%, respectively. No endoleaks, aneurysm rupture, thromboembolism, or limb loss occurred at follow-up. CONCLUSION: Stent-graft exclusion of PAAs is safe and effective, yielding primary and secondary patency rates comparable to surgical repair. In spite of encouraging results in this study, further larger studies are warranted to reconfirm our observations.

Endovascular repair of paraanastomotic aneurysms after aortic reconstruction.

We designed this retrospective study to evaluate the effectiveness of percutaneous approaches for repair of paraanastomotic aneurysms that develop after surgical aortic reconstruction. The catheterization records of patients who had undergone percutaneous repair of para-anastomotic aneurysms from January 2001 through December 2005 were reviewed, and data regarding preoperative aneurysm size, risk factors, intraoperative techniques, morbidity, and death were recorded. Eight patients had undergone exclusion of a total of 10 paraanastomotic aneurysms. The average age of the prosthetic graft at diagnosis was 11.7 years. Four of the patients were symptomatic; none of these had a ruptured aneurysm. All patients received commercially available devices. Technical success was achieved in all patients. Conscious sedation alone was administered to 7 patients. There were no in-hospital deaths, and morbidity was minimal. We conclude that endovascular exclusion of paraanastomotic aneurysms after aortic reconstruction is a viable alternative to open surgical repair and greatly reduces the risk of morbidity and death.

Endovascular repair of a ruptured descending thoracic aortic aneurysm.

Endovascular aneurysm repair has considerable potential advantages over the surgical approach as a treatment for thoracic aortic rupture, in part because open surgical repair of ruptured thoracic aortic aneurysms is associated with high mortality and morbidity rates. We describe the successful endovascular deployment of stent-grafts to repair a contained rupture of a descending thoracic aortic aneurysm in an 86-year-old man whose comorbidities prohibited surgery. Two months after the procedure, magnetic resonance angiography showed a patent stent-graft, a patent left subclavian artery, and complete exclusion of the aneurysm.

Celiac artery aneurysm: a case report.

Aneurysm of the celiac artery is an uncommon clinical problem; fewer than 180 cases have been reported in the world medical literature. Most patients are symptomatic at the time of diagnosis. However, occasionally such aneurysms are detected incidentally during diagnostic imaging for other diseases. We present the case of a 72-year-old man who had an asymptomatic celiac artery aneurysm detected by computed tomographic angiography after endoluminal exclusion of an infrarenal aortic aneurysm. The patient underwent successful resection of the aneurysm and revascularization of the aorta-common hepatic and splenic arteries with use of an autologous saphenous vein graft.