Simultaneous Transcatheter Aortic Valve Implantation and Infrarenal Aortic Aneurysm Repair for Severe Aortic Stenosis and Abdominal Aortic Aneurysm: Report of 2 Cases and Literature Review

Abstract

The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population. Both conditions have adverse outcomes, if not adequately managed. No clear recommendations are available in the literature until today, in regards of the management sequence making thus the decision-making challenging. We report 2 cases of AAA and significant AS treated with endovascular aortic repair (EVAR) and transcatheter aortic valve implantation (TAVI) during the same procedure and a review of the literature on this topic. Based on our experience, the combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential.

Keywords

abdominal aortic aneurysm endovascular aortic repair transcatheter aortic valve replacement aortic valve stenosis combined procedure

Introduction

The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population, involving about 6% of the patients undergoing transcatheter aortic valve implantation (TAVI).¹ Traditionally, planning of aortic valve replacement (AVR) and treatment of AAA was proposed in 2 stages while simultaneous repair has been advocated only in patients with extremely large or symptomatic AAA, mainly due to concerns regarding the high risk of rupture after open aortic valve replacement.^2,3 To overcome the high mortality rate and to decrease the intensity of the simultaneous open repair in such patients, TAVI followed by endovascular aortic aneurysm repair (EVAR) has been reported during the last decade as one stage attractive and less invasive alternative strategy.^4,5 We present 2 cases of combined EVAR and TAVI and a review of the literature on this topic. The patients’ consent to use the data for research purposes was obtained.

Case Reports

Case 1

A 78-year-old male was referred to our vascular surgery department with an ultrasound-based diagnosis of infrarenal AAA for endovascular aneurysm treatment. Computed tomography scanning confirmed the presence of a large infrarenal aortic aneurysm of 60 × 58 mm. The patient had a history of coronary artery bypass graft surgery (CABG; 2 grafts: left internal mammary artery [LIMA] to left anterior descending artery [LAD] and saphenous vein graft [SVG] to obtuse marginal artery [OMA]) 19 years ago, and multiple comorbidities including hypertension, chronic obstructive pulmonary disease (oxygen therapy at home), and prostate surgery 3 years ago. In addition, during the last year he had multiple hospitalizations for severe heart failure symptoms (dyspnea and peripheral edema; NYHA class III), and he was recently diagnosed with severe AS. Transthoracic echocardiography (TTE) showed the presence of severe AS (max velocity 4.6 m/s, mean gradient 50 mm Hg, area 0.8 cm²) and an ejection fraction of 50% with moderate concentric hypertrophy. An updated coronary angiogram also showed significant stenosis (90% diameter stenosis) in the native LAD distal to the graft anastomosis, an occluded SVG to the OMA, and significant stenoses in the native left circumflex artery (90% diameter stenosis), which was dominant, and the OMA. The patient was then referred to the local Heart Team (multidisciplinary team including cardiologists, cardiac and vascular surgeons, anesthesiologists) for evaluation. Due to the history of CABG and the high surgical risk (Euroscore 20.6%), the multidisciplinary heart team meeting recommended that the patient undergoes percutaneous coronary intervention (PCI) in the LAD and LCx/OMA at 2 stages, and then at a third stage, simultaneous transfemoral TAVI and EVAR.

Two weeks after successful percutaneous interventions to the LIMA/LAD and native LCx, the patient was admitted for the combined TAVI and EVAR procedure. Under general anaesthesia, bilateral femoral access was obtained. A 14-French (F) sheath was introduced into the right common femoral artery. A 29-mm Core-Valve Evolut R (Medtronic Inc) was easily advanced and deployed across the aortic annulus (Figure 1). After TAVI, EVAR was performed using the same access site as that used for TAVI. The 28 × 16 × 166 mm main body of a bifurcated Endurant endoprosthesis (Medtronic Inc) was deployed within the AAA through the common right femoral artery. An additional contralateral 16 × 16 × 93 mm leg extension was implanted to completion the left common iliac leg, with subsequent post dilatation with 32-mm diameter Reliant aortic balloon (Medtronic Inc). The procedure was completed without complication with an excellent final angiographic image (Figure 2). Total contrast media was 385 mL, and fluoroscopy time was 37 minutes. Transthoracic echocardiography performed 2 days after TAVI showed no aortic regurgitation, a peak transvalvular pressure gradient of 23 mm Hg, and an ejection fraction of 50%. The patient was discharged 10 days after the procedure. No symptoms or adverse cardiovascular events were reported at 2 years follow-up.

Case 2

An 88-year-old male was admitted to the cardiology department for worsening symptoms of shortness of breath on exertion (NYHA III). He was an ex-smoker with known AS as well as hip surgery and nephrolithiasis in the past. He also had a history of coronary artery disease with PCI in the LAD 11 years ago. A coronary angiogram showed patent stent and new significant disease in the right coronary artery (RCA), while TTE revealed severe AS (AV Vmax 5.1 m/s, AV mean gradient 63 mm Hg, Doppler velocity index 0.24) with moderate concentric hypertrophy and preserved left ventricular systolic function (ejection fraction 65%). The case was reviewed by the Heart Team and due to high risk surgical mortality management with a sequence of PCI and TAVI was regarded as the appropriate management. He underwent PCI in the RCA, and after 2 days he underwent permanent pacemaker implantation due to long pauses during the PCI and a positive carotid sinus massage while the baseline electrocardiogram was showing first degree heart block.

After PCI, the work-up computed tomography angiography showed an infrarenal abdominal aortic aneurysm measuring 66 × 62 cm. He was then referred to our Department for the management of the severe AS and the abdominal aneurysm at the same procedure based upon the previous experience.

Under general anaesthesia with bilateral femoral surgical cut down, a 16F sheath was introduced via the right femoral artery and a 34-mm Core-Valve Evolut R (Medtronic Inc) was successfully deployed (Figure 3). Subsequently, using the preexisting femoral access, under fluoroscopy a 28 × 14 × 140 mm main body of a bifurcated Excluder endoprosthesis (W. L. Gore & Associates) was deployed within the AAA with a 18 mm × 10 cm leg extension in the left common iliac artery. The final angiography revealed no complications (Figure 4). The total procedure time was 138 minutes, the total fluoroscopic time was 40 minutes, and the amount of contrast medium was 350 mL. Transthoracic echocardiography performed 2 days after transcatheter aortic valve replacement showed no aortic regurgitation, a peak transvalvular pressure gradient of 29 mm Hg, and an ejection fraction of 60%. The patient was discharged 8 days after the procedure. No symptoms or adverse cardiovascular events were reported at 1-year follow-up.

Discussion

The optimal therapeutic approach for managing patients with AAA and concomitant severe AS remains under discussion. The repair of AAA in the presence of severe AS raises the surgical risk due to the fluctuations in systolic and diastolic pressure. Additionally, the risk of AAA rupture increases after surgical correction of AS, due to the increased pressure and strain within the aneurysm.⁶ Systolic blood pressure has been recently shown as the only factor which increases after aortic valve replacement.⁷

The traditional strategy to treat concurrent AAA and severe aortic valve stenosis (AVR) was open surgical aortic valve replacement followed by open AAA. However, in the last decade in order to reduce the surgical risk in such patients, simultaneous repair using less invasive techniques like EVAR and TAVI has been advocated. To our knowledge, there have been 8 reports of similar simultaneous EVAR and TAVI in the literature for managing AAA and severe aortic valve stenosis^8

-14 (Table 1). The advantage of performing both operations at the same time is that the same access site can be used and there is no need for a second anesthetic for the second operation. The drawbacks of a combined procedure are the increased operative time and higher (combined) contrast dose.

Table 1.

Review of 10 Cases of EVAR and TAVI.

							Type and size of cardiac valve (mm)			Type and size of aortic endograft (mm)
Author	Year of publication	Type of article	Number of patients (n)	Sex	Patient(s) age	AAA size (mm)	Sapien	Core	Lotus	Endurant	Gore	Cook	Ovation	Simultaneous repair	Length of stay (days)	FU (months)
Mauri et al⁸	2019	CS	2	F	83	62	23			25				x	8	12
Mauri et al⁸	2019	CS	2	M	72		26				28			x	12	6
Sato et al⁹	2017	CR	1	M	83	57		26			26			x	8	NR
Kawashima et al¹⁵	2016	CR	1	F	91	45	23					24			9/22	NR
Marchi et al¹⁰	2014	CR	1	M	78	55	29				26			x	3	NR
Koudoumas et al¹¹	2015	CR	1	M	74	50		31					20	x	3	3
Binder et al¹²	2015	CR	1	M	67	60			27	NR	NR	NR	NR	x	NR	3
Aluko et al¹³	2015	CR	1	M	75	51	26			32				x	3	12
Chakraborty et al¹⁶	2013	CR	1	M	81	30	26				26				NR	NR
Smith et al¹⁴	2012	CR	1	M	80	70		29				24		x	5	NR
Smith et al¹⁴	2012	CR	1	M	85	70		29			x				14	6

Abbreviations: AAA, abdominal aortic aneurysm; CS, case series; CR, case report; EVAR, endovascular aortic repair; F, female; FU, follow-up; M, male; NR, no-reported; TAVI, transcatheter aortic valve implantation.

There is still no consensus over which procedure should be performed first. If we perform EVAR first, we can prevent vascular injury due to the delivery of the valve device, as well as aneurysmal sac rupture due to high blood pressure after the implantation of the prosthetic valve or during the advancement of the prosthetic valve. In addition, the TAVI procedure may cause distal embolization if there is a clot within the aneurysmal sac, which can be avoided by performing EVAR first. However, performing TAVI first reduces the risk of local thrombosis, which is possible when a large introducer sheath (14F-18F) has remained in the prosthetic leg for a long period of time, despite the systematic heparinization of the patient. In addition, using this strategy the risk of endograft injury and possible complications crossing the aorto-iliac prosthesis may be reduced.

To avoid the later intraprocedural risks, we preferred to perform TAVI first followed by EVAR in both cases. Our strategy was based on the relatively small dimension of the AAAs and the status of the aorta which was free of complicated plaques and endoluminal dissection. It is worth mentioning that the combined procedure was successfully completed with procedural time and total amount of contrast medium within reasonable limits.

In conclusion, based on our experience the combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while it reduces the risks associated with the perioperative period after open repair. In such cases, detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team is essential.

Footnotes

Authors’ Note

Stylianos Koutsias and Georgios Karaolanis contributed equally to this work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Georgios I. Karaolanis

Michail I. Papafaklis

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