Traumatic Transcatheter Aortic Valve Replacement

J INVASIVE CARDIOL 2023;35(7):E389-E391. doi: 10.25270/jic/22.00351

Key words: Transcatheter aortic valve replacement, balloon rupture, aorto-bi-iliac bypass graft

A 76-year-old female with severe symptomatic aortic stenosis underwent cardiac CT angiography imaging. Severe calcification of the ascending aorta (porcelain aorta) (Figures 1A and 1B) precluded surgical aortic valve replacement. The aortic annular area, perimeter, and diameter were 372 mm², 68.5 mm, and 20 mm, respectively. Transcatheter aortic valve replacement (TAVR) was performed with direct implantation of a 23 mm Sapien S3 valve (Edwards Lifesciences). The valve was delivered via the right femoral artery and a pigtail catheter was delivered to the aortic root via the left femoral artery. The balloon ruptured during valve implantation (Video).

During removal of the burst balloon, it became entangled with the pigtail catheter within the abdominal aorta and both were pulled into the right iliac artery (Figure 1C). Maneuvers to separate the 2 catheters were followed by pulseless electrical activity, which was attributed to massive bleeding. An occlusive balloon (REBOA) 40 mm in diameter (Figure 1D) was immediately delivered via the left femoral artery and inflated within the abdominal aorta in order to prevent further bleeding. Angiography revealed bleeding at the aortic bifurcation (Figure 1E). Attempted vascular repair by stent graft implantation failed. The patient underwent emergency laparotomy in the catheterization laboratory, with placement of an aorto-bi-iliac Dacron bypass graft. The ruptured balloon (Figure 1F) and intertwined pigtail catheter were removed. The patient stabilized following massive blood transfusion. Post-procedural echocardiography demonstrated excellent function of the implanted valve and CT angiography revealed intact aorto-bi-iliac vascular grafts (Figure 1G). The patient was discharged to her home 43 days post-procedure.

The case highlights the risk of balloon rupture during TAVR in the presence of porcelain aorta, risk of vascular injury during removal of a ruptured balloon, and strategies for managing catastrophic vascular injury.

Affiliations and Disclosures

From the ¹Department of Vascular Surgery, Lady Davis Carmel Medical Center, Haifa, Israel; ²Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel.

Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein. The authors affirm that the images have not been previously published.

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

Manuscript accepted December 8, 2022.

Address for correspondence: Ronen Jaffe, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa, Israel. Email: jaffe@clalit.org.il