Long-Sheath Assisted Transcatheter Aortic Valve Replacement: The Best and Worst Cases

J INVASIVE CARDIOL 2023;35(4):E221-E222.

Key words: aortic dissection, long sheath, tortuous aorta, transcatheter aortic valve replacement, vascular complication

Transfemoral transcatheter aortic valve replacement (TAVR) is quite challenging in patients with tortuous aorta. Recently, the combined method of buddy-wire and long-sheath use was reported.^1,2 We experienced 2 cases having tortuous aorta undergoing transfemoral TAVR following opposite clinical courses.

Case 1. An 88-year-old woman with saccular abdominal aortic aneurysm and tortuous aorta underwent transfemoral TAVR using a 65-cm 18-Fr DrySeal sheath (W.L. Gore) (Figures 1A-1C). A 23-mm Sapien 3 valve (Edwards Lifesciences) was uneventfully deployed and demonstrated excellent valve function.

Case 2. An 84-year-old woman with tortuous aorta and horizontal aortic root underwent transfemoral TAVR (Figures 1D, 1E). A 65-cm 18-Fr DrySeal sheath was inserted using a stiff guidewire and a 23-mm Sapien valve was deployed (Figure 1F). Postprocedure aortography showed an ascending aortic dissection (Figure 1G) and computed tomography and surgical inspection determined the dissection entry at the distal ascending aorta, which was corresponding to the tip of the long sheath (Figures 1H, 1I).

A long-sheath supported transfemoral approach is an effective method in patients with tortuous aorta; however, the tip of a large-bore sheath could cause an aortic injury during the procedure. The advantage of the transfemoral approach and risk of aortic injury should be counterbalanced, especially in patients with fragile tortuous aorta.

References

1. Kaneko U, Hachinohe D, Kobayashi K, et al. Combined use of ultra-long sheath and buddy wire technique to deliver SAPIEN 3 valve. JACC Cardiovasc Interv. 2022;15(7):789-790. Epub 2022 Mar 16. doi:10.1016/j.jcin.2022.01.288

2. Yang Y, Yang H, Pan J, et al. Strategies to address extreme aortic tortuosity during transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2022;15(7):791-792. Epub 2022 Mar 16. doi:10.1016/j.jcin.2022.01.305

Affiliations and Disclosures

From the Departments of ¹Cardiology and ²Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan.

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 September 21, 2022.

Address for correspondence: Ryosuke Higuchi, MD, Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu, Tokyo 183-0003, Japan. Email: rhiguchi@shi.heart.or.jp