Percutaneous Management of Vascular Complications Following Trans-Subclavian Transcatheter Aortic Valve Replacement

J INVASIVE CARDIOL 2020;32(12):E379. 

Key words: access-site complications, percutaneous, stent-graft, subclavian, transcatheter aortic valve replacement

We present 2 cases of vascular complications following trans-subclavian transcatheter aortic valve replacement (TAVR) that were managed percutaneously. The first patient was an 86-year-old woman with severe aortic stenosis and peripheral vascular disease who underwent implantation of a 26 mm CoreValve (Medtronic) via an 18 Fr sheath, which was surgically inserted into the left subclavian artery. During sheath withdrawal, traction upon the vessel was noted (Video 1). Due to concern regarding vessel injury, a 6 Fr catheter was positioned via transfemoral access at the origin of the left subclavian artery. Continued tension on the sheath resulted in avulsion of the artery. An 8 mm balloon was immediately advanced into the vessel stump and inflated, and achieved hemostasis (Figure 1A). The patient remained hemodynamically stable with no blood loss and was transferred to the operating room, where vascular repair was performed (Figure 1B). Our second patient was an 85-year-old woman who underwent direct implantation of a 26 mm Evolut R valve (Medtronic) after insertion of a 14 Fr sheath into the left subclavian artery. After surgical closure of the vascular access site, the patient was returned to the department, where ischemia of the left arm was noted. Repeat angiography revealed occlusion of the left subclavian artery at the access site (Figure 1C). Vessel patency was achieved following implantation of a 6 x 60 mm Fluency stent-graft (Bard) (Figure 1D). 

These cases demonstrate the potential for vascular complications following trans-subclavian TAVR and the role of percutaneous intervention in managing such situations.

From the Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel.

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.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted February 28, 2020.

Address for correspondence: Ronen Jaffe, MD, Cardiology Department, Lady Davis Carmel Medical Center, 7 Michal Street, Haifa, Israel 34362. Email: jafferonen@gmail.com or jaffe@clalit.org.il