Transcaval Transcatheter Aortic Valve Replacement

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Transcatheter aortic valve replacement (TAVR) is an established minimally invasive approach and an alternative to surgical aortic valve replacement (SAVR) for treatment of severe aortic stenosis in patients with high surgical risk. Transfemoral access is the most common route for TAVR and preferred in clinical routine. Alternative techniques such as the direct aortic, transapical, or subclavian access are also established for TAVR, when surgical aortic valve replacement is not appropriate. In patients who are not considered eligible for any of these options, the transcaval access, as firstly described by Lederman and colleagues, is a promising novel approach for TAVR (1).

Patient

A seventy-six-year-old man was admitted to the hospital for treatment of symptomatic severe aortic stenosis (AS). Past medical history included grade IV chronic obstructive pulmonary disease (COPD), peripheral arterial disease, coronary artery disease, and atrial fibrillation. 

This patient was evaluated for TAVR. Examination included performance of echocardiography, coronary angiography, and computer tomography (CT).

The patient was not eligible for a traditional TAVR route because of presentation of peripheral femoral stenosis, severe subclavian stenosis, severe aortic calcification, and unfavorable left ventricle (LV) apex position. Finally, transcaval access was chosen for TAVR.

The Procedure

Transcaval TAVR was performed according to the technique first described by Lederman and colleagues (1). First, necessary vascular accesses were established. Left femoral arterial access was established for the aortography, snaring, and tensioning. Right jugular vein access was established for temporary pacemaker, and right femoral vein for transcatheter valve delivery.

After establishing vascular accesses, a simultaneous cavography and aortography were performed for correct caval-aortic crossing positioning. Caval-aortic crossing was performed using angiographic guidance. Once the wire and snare system were locked, the combined transcatheter system was advanced in tandem into the thoracic aorta. 

As the next step, a pigtail catheter was placed via the left femoral artery in the noncoronary cusp. A stiff guide wire via the right femoral vein and the caval-aortic tract were placed in the left ventricle for TAVR delivery guidance. Next, the expandable TAVR sheath was advanced from the femoral vein to the descending aorta using the caval-aortic tract.

TAVR was then performed under angiographic guidance. Thereafter, the caval-aortic access tract was closed using a ventricular septum defect (VSD) occluder. Final cavography and aortography assured a correct position of the occluder device and excluded extravasations.

Post-TAVR CT could confirm correct position and function of the VSD occluder. Furthermore, no extravasation was noticed. At the patient’s follow up, echocardiographic examination could assure correct aortic prosthesis function.

References

1. Lederman RJ, Babaliaros VC, Greenbaum AB. How to perform transcaval access and closure for transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2015 Dec 1;86(7):1242-54. doi: 10.1002/ccd.26141. Epub 2015 Sep 10. PMID: 26356244; PMCID: PMC4740457.

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