Aortic Rupture in Transcatheter Aortic Valve Replacement

A 95-year-old man with severe symptomatic aortic stenosis was admitted for elective transcatheter aortic valve replacement (TAVR). He had balloon aortic valvuloplasty 1 year prior with aortic valve restenosis resulting in dyspnea on minimal exertion. The patient pursued TAVR for improvement in quality of life. His preprocedure computed tomography (CT) scan demonstrated moderate aortic and iliofemoral atherosclerosis. TAVR was performed in a hybrid theater with bilateral femoral arterial access. After crossing the aortic valve and recording peak-to-peak aortic valve gradient of 48 mm Hg, a stiff wire was placed in the left ventricle. The valve delivery system was passed over this, but would not easily cross the aortic arch. The patient became distressed and hypotensive. The aortogram demonstrated large aortic injury distal to the left subclavian artery origin with significant extravasation (Figure 1 and Video 1). The patient had pulseless electrical activity. Despite cardiopulmonary resuscitation, rapid blood transfusion, and covered stenting of aortic injury, the patient did not survive.

This case demonstrates a rare but catastrophic complication of TAVR. In an era where TAVR is now indicated in low-risk patients, serious complication rates are less frequent. It exemplifies the importance of preparedness for vascular injury, with readiness for vascular covered stenting and potential bail-out strategies.