Transcatheter Aortic Valve Implantation as a Bailout Procedure for Acute Aortic Valve Regurgitation During Endovascular Arch Repair

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1 719880JETXXX / Journal of Endovascular TherapyHertault et al case-report2017 A SAGE Publication Case Reports Transcatheter Aortic Valve Implantation as a Bailout Procedure for Acute Aortic Valve Regurgitation During Endovascular Arch Repair Journal of Endovascular Therapy 2017, Vol. 24(5) The Author(s) 2017 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: Adrien Hertault, MD 1, Rachel E. Clough, MD, PhD 1, Thomas Modine, MD, PhD 2, Jean-Luc Auffray, MD 3, Mohamad Koussa, MD 2, and Stéphan Haulon, MD, PhD 1 Abstract Purpose: To report emergent transcatheter aortic valve implantation (TAVI) to treat acute severe aortic regurgitation caused by valve cusp dysfunction following proximal migration of an endograft implanted in the ascending aorta during endovascular arch repair. Case Report: A 65-year-old man had been previously treated with thoracic and fenestrated endografts in a 2-stage procedure for a chronic type B dissection. At 2-year follow-up, aneurysmal evolution of the distal arch led to development of a proximal type Ia endoleak. The patient was deemed unfit for open repair because of severe nonrevascularizable coronary artery disease. A custom-made endograft was designed consisting of a double inner branch arch endograft with a proximal component to reline the ascending aorta to avoid iatrogenic type A dissection. The first component was successfully deployed. However, this device migrated toward the aortic valve when the delivery system of the branch device was advanced through the aortic valve. Aortography and transesophageal echography showed acute aortic regurgitation due to obstruction of the left coronary valve cusp. An emergency bailout TAVI procedure was performed to successfully treat the aortic regurgitation. Conclusion: TAVI can be used as a bailout procedure for acute aortic valve dysfunction during endovascular arch or ascending aorta repair. Keywords aortic arch, aortic valve, dissection, emergent procedure, endograft, migration, stent-graft, transcatheter aortic valve implantation, type Ia endoleak Introduction Endovascular repair of the aortic arch with a double inner branch device (Cook Medical, Bloomington, IN, USA) has shown promising results in the treatment of arch aneurysms in patients unfit for open repair. 1 The results from the initial global experience demonstrated that previous open repair of the ascending aorta offers a safe landing zone; in patients with a native ascending aorta and a history of aortic dissection, there is a major concern that iatrogenic dissection may occur at the interface between the proximal stent of the endograft and the ascending aorta wall. In these patients, dedicated strategies need to be designed and implemented to secure the proximal landing zone. Transaortic valve implantation (TAVI) has rapidly improved in the past few years and is now routinely used to treat symptomatic aortic valve stenosis in patients deemed at high risk from conventional surgery, 2,3 even in conjunction with thoracic endovascular aortic repair. 4 TAVI remains controversial for the treatment of patients with native aortic valve regurgitation, mostly because the size of the aortic annulus and the low degree of calcification in those patients can compromise stable fixation of the valve. However, reports of patients successfully treated with TAVI for degenerative bioprosthetic devices 5,6 or severe native aortic valve regurgitation 7 have been published. This report presents the successful use of TAVI to address iatrogenic acute aortic 1 Department of Vascular Surgery, Aortic Center, Heart and Lung Institute, University Hospital of Lille, France 2 Department of Cardiac Surgery, Aortic Center, Heart and Lung Institute, University Hospital of Lille, France 3 Department of Cardiology, Aortic Center, Heart and Lung Institute, University Hospital of Lille, France Corresponding Author: Stéphan Haulon, Aortic Centre, CHRU de Lille, INSERM U1008, Université Lille Nord de France, Lille Cedex, France. haulon@hotmail.com

2 Hertault et al 657 valve insufficiency arising during endovascular aortic arch repair. Case Report A 65-year-old man with a medical history of severe nonrevascularizable coronary artery disease had been under follow-up in our center for a chronic type B dissection since In 2014, false lumen enlargement prompted a staged repair with thoracic endograft implantation [positioned just distal to the origin of the left common carotid artery (LCCA)] associated with a left subclavian LCCA bypass, followed a few weeks later by a fenestrated endograft in the thoracoabdominal aorta to completely exclude the false lumen. Early follow-up demonstrated good results with true lumen expansion and false lumen shrinkage. At 2-year follow-up, computed tomography (CT) imaging showed a type Ia endoleak associated with significant enlargement of the distal arch (Figure 1A-C). Open repair of the arch was considered as a first-line option but declined because of the patient s cardiac condition. It was therefore decided to perform an endovascular repair. A custom-made endograft was designed to achieve sealing in the ascending aorta (Figure 1D-F). To reduce the risk of iatrogenic dissection, a proximal component (Figure 1D) was added to cover the ascending aorta from just above the coronary artery origins to the origin of the innominate trunk. A double inner branch endograft (one branch for the innominate and one for the LCCA) was designed to be implanted between the ascending and the descending aortic endografts. Both endografts were manufactured by Cook Medical. The procedure was performed under general anesthesia in a state-of-the-art hybrid room (Discovery IGS 730; GE Healthcare, Chalfont, UK) using fusion imaging guidance. Despite high aortic tortuosity and stiffness (due to the previous thoracic and fenestrated endografts), positioning of the ascending aorta endograft component under rapid pacing was achieved as planned (Figure 2A). When the delivery system of the branched component was advanced through the aortic valve into the left ventricle, the ascending arch endograft migrated toward the aortic valve (Figure 2B and C). Instantaneously, the patient developed hemodynamic instability. The branched component was deployed as planned to remove the delivery system from the aortic valve and provide supra-aortic trunk perfusion. Aortography showed that the coronary arteries were patent but severe aortic regurgitation was present. The strut of the proximal bare metal stent of the ascending endograft was obstructing the aortic valve (Figure 2D). Transesophageal echocardiography (TEE) showed the obstructing strut (Figure 2E) and no movement of the left coronary cusp. After rapid discussion with the anesthesiologist and cardiac surgical teams, it was decided to perform an emergency TAVI as a bailout procedure. Valve sizing was performed on the preoperative CT scan (Figure 2F and G) on a dedicated workstation in the hybrid room (Advantage Workstation VolumeShare 7; GE Healthcare, Chalfont, UK) confirmed by TEE measurements. The best working position to identify the valve plane was defined on the workstation (Figure 2H). A 29-mm Sapien S3 valve (Edwards Lifesciences, Irvine, CA, USA) oversized 20% was deployed successfully (Figure 2I-K), with immediate hemodynamic improvement. Aortography and TEE showed trivial paravalvular leak. The endovascular arch repair was then completed with deployment of the bridging stents into the 2 inner branches (Figure 3A). The patient was transferred to the intensive care unit. A right arm deficit was depicted when the patient awakened, and cerebral magnetic resonance imaging showed small lesions in both hemispheres. Duplex and CT scans confirmed patency of the endograft and its 2 branches and the absence of any endoleak. The patient was discharged from the intensive care unit on day 6. The patient made a good recovery and returned to the clinic at 6 months after the procedure; the right arm deficit had almost totally resolved. The CT scan (Figure 3B) and cardiac echography confirmed good postoperative findings, which were maintained at the 7-month follow-up scan (Figure 3C). Discussion The initial global experience of the double inner branch graft for endovascular repair of aortic arch aneurysms or chronic dissections has demonstrated promising results in patients unfit for open repair, offering a better proximal sealing zone than the native aorta and eliminating the risk of iatrogenic dissection in patients with previous open repair of the ascending aorta. 1,8 To avoid the latter complication, the strategy in the current case was to reline the nondilated ascending aorta from the sinotubular junction to the origin of the innominate trunk with a tubular endograft, using limited oversizing (15%). The proximal landing zone was thus reinforced before implantation of the double inner branch endograft. The procedure plan was to first focus on accurate positioning of the ascending endograft just distal to the coronary origins; the accurate positioning of the arch branched endograft would follow. However, the proximal component migrated toward the aortic valve as the delivery system of the branched graft was advanced. To avoid this complication, a branched endograft with a longer proximal sealing zone (3 proximal stents) could have been designed, which would have negated the need for a separate device for the ascending aorta. It is, however, difficult to design such an endograft because it is challenging to precisely evaluate how the endograft will adapt to such a tortuous anatomical segment. Overlapping 2 endografts appeared to be a better option. Another option to avoid this complication would be to insert the ascending aorta endograft from one groin and deploy it without releasing the distal trigger wire, thereby keeping the device attached to the delivery system. The arch branched component would then be inserted from the other

3 658 Journal of Endovascular Therapy 24(5) Figure 1. Two years after thoracoabdominal repair with a fenestrated endograft, distal arch aneurysmal evolution was seen, associated with proximal endograft migration and endoleak in the (A) axial and (B) oblique multiplanar reconstructions and (C) 3-dimensional volume rendering. (D) The plan of the proximal ascending endograft and of (E) the double inner branched (red diamonds) endograft provided by the manufacturer. (F) Anatomical sketch showing the expected position of the endografts. groin. Finally, the ascending endograft could have been manufactured with barbs facing toward the aortic valve to prevent proximal migration. TAVI is not routinely used in aortic regurgitation because of the aortic annulus diameter and the lack of calcification. However, successful reports have been published in this setting. 7 In pure native valve aortic regurgitation, the Corevalve prosthesis (Medtronic, Minneapolis, MN, USA) has demonstrated acceptable results in 43 patients, 6 but the authors emphasized that in many cases implantation of a second

4 Hertault et al 659 Figure 2. (A) The ascending arch endograft was deployed as planned. During advancement of the branched endograft delivery system, (B, C) the ascending endograft was pushed toward the valve. (D) Aortography showed patent coronary arteries but severe aortic regurgitation. (E) Transesophageal echocardiography showed the left main trunk cusp pinned to the aortic wall by the endograft (white arrow). Black arrow shows a free cusp. (F, G) The aortic annulus was evaluated on the preoperative images to select the appropriate valve size. (H) Views perpendicular to the annulus plane were automatically defined by the software and sent to the C-arm to assist accurate valve deployment. (I) The balloon-expandable Sapien S3 prosthesis was positioned through the aortic valve. (J) Deployment was performed under rapid pacing. (K) The sheath and wire were then retrieved.

5 660 Journal of Endovascular Therapy 24(5) Figure 3. (A) Final angiography showing no aortic regurgitation or endoleak with patency of the coronary arteries and bridging stents perfusing the supra-aortic trunks. Results were confirmed on the postoperative 3-dimensional reconstruction (B) and maintained on the 7-month follow-up scan. valve was deemed necessary because technical success was not achieved. Mangieri et al 9 published a case of severe traumatic aortic valve regurgitation in a patient with a large aortic annulus, which was successfully treated using a selfexpanding valve (Direct Flow Medical, Santa Rosa, CA, USA). In the current case, the regurgitation was also traumatic and the annulus diameter ranged from 23 to 30 mm, with a perimeter evaluated at 86 mm 2. A balloon-expandable Sapien S3 valve was selected with 20% oversizing to compensate for the absence of calcifications and the large annulus size. The S3 valve was preferred because the short length of this prosthesis reduced the risk of conflict with the ascending endografts and lowered the risk of coronary artery occlusion in this anatomy. In addition, the catheter (Edwards Commander delivery system; Edwards Lifesciences) provided with this valve, offered a very stable platform to advance the valve through very challenging tortuous and stiffened (because of the endografts) aortic anatomy. Conclusion TAVI can be used as a bailout procedure for traumatic aortic valve regurgitation during endovascular ascending and aortic arch repair. Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Adrien Hertault is a consultant for GE Healthcare. Thomas Modine is a consultant for Edwards Lifescience. Stéphan Haulon is a consultant for GE Healthcare and Cook Medical. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Haulon S, Greenberg RK, Spear R, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg. 2014;148: Leon MB, Smith CR, Mack M, et al. Transcatheter aorticvalve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363: Makkar RR, Fontana GP, Jilaihawi H, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012;366: De Backer O, Lönn L, Søndergaard L. Combined surgical and catheter-based treatment of extensive thoracic aortic aneurysm and aortic valve stenosis. Catheter Cardiovasc Interv. 2015;85:E95 E Fairley SL, Jeganathan R, Manoharan G, et al. Early experience of implantation of the new CoreValve Evolut in degenerated bioprosthetic aortic valves. Catheter Cardiovasc Interv. 2014;83: Gonska B, Seeger J, Rodewald C, et al. Transfemoral valvein-valve implantation for degenerated bioprosthetic aortic valves using the new balloon-expandable Edwards Sapien 3 valve. Catheter Cardiovasc Interv. 2016;88: Roy DA, Schaefer U, Guetta V, et al. Transcatheter aortic valve implantation for pure severe native aortic valve regurgitation. J Am Coll Cardiol. 2013;61: Spear R, Haulon S, Ohki T, et al. Subsequent results for arch aneurysm repair with inner branched endografts. Eur J Vasc Endovasc Surg. 2016;51: Mangieri A, Latib A, Aurelio A, et al. Successful implantation of a second-generation aortic valve in severe aortic regurgitation secondary to a traumatic cusp lesion. Cardiovasc Revasc Med. 2015;16: