Balloon valvuloplasty and transcatheter aortic valve replacement via aortofemoral bypass grafts: A case report and review of literature

Abstract

BACKGROUND

Transcatheter aortic valve replacement (TAVR) can be performed through multiple access sites with the preferred approach being transfemoral. In patients with severe peripheral arterial disease and previous grafts, the safety of transfemoral access via direct graft puncture, especially when performed twice within a short period, remains unclear compared to alternative access methods. We present a case demonstrating the safety and efficacy of direct graft puncture for transfemoral access during balloon aortic valvuloplasty (BAV) and TAVR.

CASE SUMMARY

An 82-year-old man presented with dyspnea on exertion. Echocardiogram was significant for severe aortic stenosis. Following a heart team discussion, the patient was scheduled for a balloon valvuloplasty followed by staged TAVR. Based on pre-TAVR computed tomography angiogram, the aortobifemoral graft was deemed as an appropriate access site. Micropuncture needle was used to access the right femoral artery graft, and the sheath was upscaled to 10 Fr. He underwent successful intervention to ostial left anterior descending and left circumflex arteries, and BAV with 22 mm Vida BAV balloon. Hemostasis was achieved using Perclose. For TAVR, an 8 Fr sheath was inserted via the right femoral bypass graft. The arteriotomy was pre-closed with two Perclose ProGlides and access was upsized to 18F Gore DrySeal. A 5Fr sheath was used for left femoral bypass graft access. Patient underwent successful TAVR with 29 mm CoreValve. Hemostasis was successfully achieved using 2 Perclose for right access site and one Perclose for left side with no postoperative bleeding complications.

CONCLUSION

BAV and TAVR are feasible and safe through a direct puncture of the aortofemoral bypass graft with successful hemostasis using Perclose.

Keywords: Balloon aortic valvuloplasty; Aortic valve replacement; Aortic stenosis; Aortofemoral bypass grafts; Case report

Core Tip: This case report focuses on the safety and efficacy of a direct puncture of an aortofemoral graft for transfemoral access to perform balloon aortic valvuloplasty and a staged transcatheter aortic valve replacement (TAVR) within a short time frame in a patient with severe peripheral arterial disease. While alternative non-femoral access approaches are reasonable, we chose direct graft puncture as the ideal access based on multi-detector computed tomography imaging. This demonstrates the safety of obtaining large-bore catheter access twice through an aortofemoral graft. Our case adds to the literature by exploring the short-term outcomes of puncturing an avascular structure during TAVR in a complex patient. This transfemoral approach may be considered in patients with aortofemoral grafts when general anesthesia or alternative access methods are less desirable.