Percutaneous Aortic Balloon Valvuloplasty Performed in a Patient with Distal Aortic Occlusion

ABSTRACT: We present a case of successful percutaneous aortic balloon valvuloplasty performed via surgical cut down of the right brachial artery in a patient with distal aortic occlusion. We describe the procedural technique and review the literature on alternative access sites that have been used to perform percutaneous aortic balloon valvuloplasty.

J INVASIVE CARDIOL 2012;24(4):E75-E76

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Case Report

A 72-year-old female with morbid obesity, debilitating rheumatoid arthritis requiring chronic oral steroid therapy, hypertension, and hyperlipidemia was referred for evaluation of severe, symptomatic aortic stenosis. She was refused for surgical intervention given multiple comorbid conditions, EuroSCORE of 12%, morbid obesity, severe physical deconditioning, and the need for chronic steroid therapy.

Diagnostic cardiac catheterization showed occlusion of the distal abdominal aorta, single vessel coronary artery disease with a chronic total occlusion of the mid right coronary artery, and normal left ventricular systolic function (Figure 1). The maximum and mean gradients across the aortic valve were 50 and 26 mm Hg, respectively. The aortic valve area was 0.87 cm² and the aortic valve index was 0.37 cm2/m². Ongoing congestive heart failure symptoms despite medical therapy mandated treatment for aortic stenosis. Access to the aorta via the femoral arteries was not deemed possible given the length of the distal aortic occlusion. Alternative access sites were considered and the brachial artery was chosen. Access to the right brachial artery was achieved using a surgical cut down approach. With blunt dissection, the right brachial artery was exposed. A small, longitudinal incision was made on the anterior surface of the artery and a .035-inch Wholey wire (Covidien) was inserted. Under direct visualization of the brachial artery, a 6 Fr sheath (Super Sheath, Boston Scientific) was inserted. Using a pigtail catheter and a 0.35-inch straight wire (Boston Scientific), the aortic valve was crossed. Simultaneous pressures within the aorta and the left ventricle were measured using a double lumen Langston catheter (Vascular Solutions Inc.). A .035-inch apex wire (Cook Medical) was advanced and coiled within the left ventricular apex. The 6 Fr sheath was removed over the apex wire. A 20 mm x 50 mm balloon (Nucleus, NuMED, Inc.) was inserted into the brachial artery under direct visualization via the arteriotomy site. With gentle retraction of the apex wire as the balloon was advanced into the brachial artery, there was no significant resistance. The balloon was placed across the aortic valve and inflated with complete balloon expansion. A second balloon inflation was performed with complete balloon expansion. Final mean and maximum gradients across the aortic valve were 20 mm Hg and 40 mm Hg, respectively. Hemostasis of the right brachial artery was achieved by direct surgical repair of the arteriotomy site. An echocardiogram the following day showed no evidence of aortic regurgitation and an aortic valve area of 1.2 cm². The patient recovered well and was discharged from the hospital on day 3.

Discussion

The femoral artery is the traditional approach to perform percutaneous aortic balloon valvuloplasty (PABV). In our patient, distal aortic occlusion rendered access via the femoral artery impossible and an alternative route was required. Alternative approaches to perform PABV include the brachial, axillary, and subclavian arteries, and a transvenous transseptal (antegrade) approach. In pediatric patients, alternative access sites are more commonly used due to a concern for femoral artery complications.^1,2 In the initial series of PABV reported by Cribier et al in 1986, all 3 patients described underwent the procedure using the brachial artery approach.³ The authors chose this access site because they felt it was easier to cross the stenosed aortic orifice and the short length (60 cm) of the dilation catheters that were available at the time. There were no vascular complications encountered in these 3 patients. The brachial artery approach has fallen out of favor as physicians transitioned to the femoral artery over the last several years. For example, the Mansfield Scientific Aortic Valvuloplasty Registry performed from 1986 to 1987 used the brachial artery approach in only 6% of the 492 patients included.⁴

An additional means to perform PABV in the setting of aortic occlusion or severe peripheral vascular disease is from a transvenous transseptal (antegrade) approach.⁵ While the hemodynamic benefits appear to be similar when comparing retrograde versus antegrade PABV, vascular complications with antegrade PABV are significantly lower.^6-8 Placement of large caliber catheters within the femoral vein with the antegrade approach, as opposed to the femoral artery with the retrograde approach, explains this difference in vascular complications.

In summary, for patients with an aortic occlusion or severe peripheral vascular disease, the brachial artery approach performed with a surgical cut down represents an option to perform PABV.

References

1. Rossi RI, Manica JL, Petraco R, Scott M, Piazza L, Machado PM. Balloon aortic valvuloplasty for congenital aortic stenosis using the femoral and the carotid artery approach: a 16-year experience from a single center. Catheter Cardiovasc Interv. 2011;78(1):84-90.
2. Borghi A, Agnoletti G, Poggiani C. Surgical cutdown of the right carotid artery for aortic balloon valvuloplasty in infancy: midterm follow-up. Pediatr Cardiol. 2001;22(3):194-197.
3. Cribier A, Savin T, Saoudi N, Rocha P, Berland J, Letac B. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet. 1986;1(8472):63-67.
4. McKay RG. The Mansfield Scientific Aortic Valvuloplasty Registry: overview of acute hemodynamic results and procedural complications. J Am Coll Cardiol. 1991;17(2):485-491.
5. Cubeddu RJ, Jneid H, Don CW, et al. Retrograde versus antegrade percutaneous aortic balloon valvuloplasty: immediate, short- and long-term outcome at 2 years. Catheter Cardiovasc Interv. 2009;74(2):225-231.
6. Block PC, Palacios IF. Comparison of hemodynamic results of anterograde versus retrograde percutaneous balloon aortic valvuloplasty. Am J Cardiol. 1987;60(8):659-662.
7. Sakata Y, Syed Z, Salinger MH, Feldman T. Percutaneous balloon aortic valvuloplasty: antegrade transseptal vs. conventional retrograde transarterial approach. Catheter Cardiovasc Interv. 2005;64(3):314-321.
8. Eisenhauer AC, Hadjipetrou P, Piemonte TC. Balloon aortic valvuloplasty revisited: the role of the inoue balloon and transseptal antegrade approach. Catheter Cardiovasc Interv. 2000;50(4):484-491.

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From the ¹Department of Internal Medicine, and the ²Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted October 12, 2011 and accepted November 1, 2011.
Address for correspondence: David M. Shavelle, MD, FACC, FSCAI, Keck School of Medicine, University of Southern California, Division of Cardiovascular Medicine, 1510 San Pablo Street, Suite 322, Los Angeles, CA 90033. Email: shavelle@usc.edu