Brachiocephalic artery access in transcatheter aortic valve implantation: a valuable alternative: 3-year institutional experience.

OBJECTIVES: With the expanding use of transcatheter aortic valve implantation (TAVI), we have encountered increasing numbers of patients without ideal femoral access. Although many alternatives have been described, vascular access and access-related complications remain a point of concern. We report our series of 20 patients undergoing TAVI via brachiocephalic artery access. METHODS: Between September 2011 and May 2014, we performed 107 consecutive CoreValve bioprosthesis implantations, of which 20 were by the brachiocephalic approach due to unfavourable iliac or femoral anatomy. RESULTS: No vascular or access-related complications were seen. Procedural feasibility, device success and early safety, as defined by the Valve Academic Research Consortium-2 criteria, were good, at 100, 95 and 95%, respectively. No stroke, transient ischaemic attack, acute kidney injury, major vascular or major bleeding complications were observed. At a mean follow-up of 497 days, the 1-year survival rate is 75.0%. Echocardiography at discharge confirmed moderate paravalvular regurgitation in 1 patient and mild paravalvular leakage in 3 patients, and no paravalvular leak more than moderate was seen. Echocardiography at discharge, 6 months and 1 year after TAVI confirmed persistent low mean transvalvular gradients (9, 9 and 10 mmHg, respectively). CONCLUSIONS: TAVI implantation through the brachiocephalic artery is safe and feasible. The distance between the point of access and the aortic valve annulus is short, improving catheter stability and implant site accuracy. We consider it to be a valuable alternative in patients without femoral access.

Disseminated malignancy after extracorporeal life support and left ventricular assist device, diagnosed by left ventricular apical core biopsy.

The left ventricular apical core biopsy performed during implantation of a left ventricular assist device (VAD) is a well-known diagnostic procedure in confirming cardiomyopathies leading to end-stage heart failure. We describe a patient in whom disseminated malignancy was revealed by means of the apical core biopsy after extracorporeal life support and left ventricular assist device implantation as a bridge to transplantation. This case emphasizes the importance of thorough oncological screening before VAD implantation and the possible consequences of circulating tumour cells in this device-assisted circulation.

Alternative access in transcatheter aortic valve implantation: brachiocephalic artery access.

Direct ascending aortic access is an accepted alternative approach for transcatheter aortic valve implantation (TAVI) that can be preferred in case of excessive atherosclerosis or small caliber of femoral and subclavian vessels or after previous coronary artery bypass grafting with a patent left internal mammary artery graft. However, not all patients are suitable for this direct aortic approach. In these patients, we now use direct access through the brachiocephalic artery. The direct brachiocephalic access can be obtained with or without partial upper sternotomy, depending on the anatomy, which should be evaluated by preprocedural angiographic computed tomography scan. During the procedure, the cerebral tissue oxygen saturation is continuously monitored. We treated two patients with severe aortic valve stenosis, classified as not suitable for surgical aortic valve replacement, by means of TAVI through the brachiocephalic artery. Both patients had excessive iliac atherosclerotic disease. One had patent left internal mammary artery and venous grafts after previous coronary artery bypass grafting so the femoral, direct aortic, nor left subclavian access was suitable; the other had a severely atheromatous and calcified aorta. No procedural or late complications were seen. If transfemoral, subclavian, and direct aortic accesses for TAVI are contraindicated, the direct brachiocephalic access seems to be a safe and feasible alternative.

The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: : To present our results and demonstrate advantages of rapid endovascular balloon occlusion (REBO) of the juxtarenal aorta in unstable patients with ruptured abdominal aortic aneurysm (rAAA). METHODS: : Since 2006, all unstable patients with rAAA are immediately transferred to the operating room (OR). No computed tomography scan is performed once diagnosis is made on ultrasound examination. Instability is defined as systolic blood pressure less than 60 mm Hg, unconsciousness, cardiac ischemia, or intubation. Once arrived in the OR, a Reliant aortic balloon is introduced and inflated at the level of the renal arteries. Subsequently, an angiogram is made through the contralateral femoral artery in order to decide between open or endovascular repair (EVAR). RESULTS: : Twelve patients with rAAA were defined as unstable. REBO was installed within 10 minutes after arrival in the OR. Aortic occlusion resulted in immediate hemodynamic stability. Five patients were suitable for EVAR. Seven patients had open repair. For these abdominal dissection was more careful since no instability was encountered. All patients survived the procedure except one. Mean stay on intensive care unit was 19.7 days for open group and 8.4 for EVAR. CONCLUSIONS: : REBO of the juxtarenal abdominal aorta by pc technique in unstable patients with rAAA resulted in a 17% 30-day mortality and a 100% 1-year event-free follow-up for survivors. With this technique, EVAR exclusion is still a valuable treatment. Exposure and decision making for the open group is easier to perform with less risk for additional damaging to neighboring structures during dissection since urgent cross-clamping is not necessary.