TAVR Complicated by Thoracic Aortic Perforation and Intussusception of the Right Iliac: Report of Successful Emergent Management With Endovascular Techniques

J INVASIVE CARDIOL 2019;31(5):E97.

Key words: EVAR, TEVAR, transcatheter aortic valve replacement

An 81-year-old male at prohibitively high surgical risk with severe aortic stenosis and extensive vascular disease developed an intraprocedural iliac artery intussusception during transcatheter aortic valve replacement (TAVR), with a mobile, calcified, tube-like cast of intimal plaque encircling the delivery catheter and interfering with valve deployment. One hour after completion of TAVR, the patient developed acute hypotension and respiratory distress and was found to have a left hemothorax. Computed tomography demonstrated focal perforation of the thoracic descending aorta, as well as residual tube-like cast of iliac intima residing in the distal aorta. Management was successful, involving early recognition, emergent vascular consultation, and immediate thoracic endovascular aortic repair (TEVAR; Video 1) for perforation of thoracic aorta and endovascular aortic repair (EVAR; Video 2) for retained iliac cast in the distal aorta. At the conclusion of the case, the patient returned to the ICU, remained stable, and was successfully extubated on post-op day 1. He was noted to be ambulating without difficulty on post-op day 2, and was transferred out of the ICU. He was discharged home on post-op day 4; when he presented for outpatient follow-up on post-op day 30, he had returned to his activities of daily living.

Percutaneous approaches have become routine in TAVR. Despite numerous advantages, vascular complications associated with percutaneous access can occur during and after TAVR, and increase morbidity and mortality significantly. Effective management of potentially catastrophic vascular complications often requires prompt recognition, diagnosis, and management by multidisciplinary teams.

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From the Sentara Heart Valve and Structural Disease Center, Norfolk, Virginia.

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 November 7, 2018.

Address for correspondence: Paul Mahoney, MD, Sentara Heart Valve and Structural Disease Center, 600 Gresham Dr, Norfolk, VA 23507. Email: paul.mahoney.md@gmail.com