Single-Stage Procedure of Transcatheter Aortic Valve Replacement and Endovascular Aneurysm Repair Under Local Anaesthesia and Percutaneous Access

Introduction

The incidence of concomitant infrarenal abdominal aortic aneurysm (AAA) and severe aortic valve stenosis (AS) increases with advancing patient age, estimated in up to 6% of patients requiring transcatheter aortic valve implantation (TAVI). ¹ Traditionally, a 2-stage procedure was recommended by guidelines, with aortic valve replacement (AVR) performed first. ²

Over the last decade, some cases of simultaneous endovascular aneurysms repair (EVAR) have been reported.^3,4 EVAR and TAVI are less invasive alternatives to traditional open repair, especially indicated for patients with intermediate/high peri-operative risk.^2,3,5

This presents a case of an elderly patient with a symptomatic AS and large AAA treated with a single-stage TAVI and percutaneous EVAR. Given the patient’s high perioperative risk, cardiac and pulmonary complications, the procedures were carried out under local anaesthesia. Informed consent was obtained from the patient for publication of this case report and accompanying images.

Case Report

An 80-year-old male was admitted to a nearby hospital for an episode of acute heart failure. The patient had a history of an infrarenal AAA, hypertension, chronic renal failure, dyslipidaemia, rheumatoid arthritis, B-cell lymphoproliferative disorder and was an ex-smoker. A transthoracic echocardiogram revealed critical severe AS with an aortic mean gradient of 41 mmHg, a valve area of .76 cm² and an impaired left ventricular systolic function with an ejection fraction of 45%. During hospitalization, coronary angiography confirmed the absence of significant coronary stenosis.

The patient was transferred to our tertiary hospital for TAVI. Pre-operative thoracic and abdominal computed tomography angiography (CTA) assessment confirmed infrarenal AAA of 55 mm; a 6 mm growth over an 8-month period compared to prior Duplex evaluation (Figure 1).

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Figure 1.

Pre-operative abdominal assessment. A thoracoabdominal computed tomography angiography was performed demonstrating an increase of the abdominal aortic aneurysm and winding bilateral iliac vessels, compared to previous assessments.

A multidisciplinary team of interventional cardiologists, vascular surgeons and anesthesiologists, proposed a simultaneous endovascular approach, TAVI immediately followed by EVAR performed through single percutaneous accesses. Due to the patient’s high cardiac and pulmonary anaesthetic risk, local anaesthesia was preferred.

The simultaneous procedures were performed in an interventional Angio suite room system (Innova IGS; GE Healtcare, Waukesha, WI, USA) with a workstation (Advantage workstation; GE Healthcare). A dose of 5000 IU of unfractionated heparin was administered during the procedure. Under local anaesthesia, a right retrograde percutaneous femoral approach was achieved. Two Perclose Prostyle (Abbott Laboratories, Chicago, IL, USA) device were deployed (“Preclose” technique) and a 16-Fr 45 cm Flexor (Cook, Bloomington, IA, USA) vascular sheath was positioned. A simultaneous left retrograde percutaneous radial approach was achieved, a 6-Fr radial vascular sheath (Terumo, Shibuya-ku, Tokyo, Japan) was positioned and a 5-Fr PigTail (Cordis, Santa Clara, CA, USA) diagnostic catheter over a .035″ 180 mm Terumo floppy guidewire (Terumo, Shibuya-ku, Tokyo, Japan) reached the aortic root for selective supravalvular aortography. A .035″ 260 mm Emerald stiff guidewire (Cordis, Santa Clara, CA, USA) was delivered through the aortic valvular plane via right femoral access. The guidewire was then replaced with a .038″ 260 mm Confida-Brecker extra-stiff guidewire (Medtronic, Minneapolis, MA, USA). The right femoral sheath was removed and a sheathless self-expandable supra-annular 34 mm Core-Valve Evolut Pro Plus (Medtronic, Minneapolis, MA, USA) was positioned and deployed across the aortic annulus during rapid pacing under fluoroscopy. Post-TAVI supravalvular angiography confirmed technical success without aortic regurgitation.

EVAR was then performed through the same percutaneous right femoral access, with an additional left retrograde percutaneous femoral approach achieved. Two Perclose Prostyle device were deployed (“Preclose” technique) prior to the insertion of an 11-Fr 10 cm (Terumo, Shibuya-ku, Tokyo, Japan) vascular sheath into the left groin. The Confida-Brecker guidewire was replaced with a .035″ 260 mm Lunderquist (Cook, Bloomington, IA, USA) extra-stiff guidewire in the right femoral access. A 16Fr main body of a tri-modular abdominal endovascular graft Zenith Alpha (ZIMB-30-108) (Cook, Bloomington, IA, USA) was advanced, positioned and deployed just below the right renal artery. Leg extensions (ZISL-20-59 and ZISL-20-77) were implanted to achieve a distal landing zone in the left common iliac artery (via left femoral access) and right common iliac artery (via right femoral access), respectively. Completion angiography confirmed successful AAA exclusion. The “Preclose” technique with Perclose Prostyle was completed bilaterally.

Over a total operative time of 190 minutes, TAVI was performed in 120 minutes and EVAR in 70 minutes. Total injected contrast medium (Iomeron 350, Bracco, Milano, Italy) was 310 mL and fluoroscopy time was 62 min.

Post-operative day 1 contrast-enhanced ultrasound confirmed successful AAA exclusion and endograft patency, without any evidence of endoleaks.

The patient was discharged on post-operative day 5 following an uneventful hospital stay. A single antiplatelet therapy (ASA 100 mg daily) was prescribed.

A thoracoabdominal CTA performed 2 months post-operatively confirmed technical success by ongoing AAA exclusion, endograft patency and the absence of any endoleak. (Figure 2). The aneurysmal sac size remained unchanged.

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Figure 2.

Post-operative surveillance. Two-month post-operative thoracoabdominal computed tomography angiography confirmed technical success, endograft patency and the absence of any endoleak.

Discussion

AS is one of the most frequent valvular diseases in the elderly population, with incidence rates of around 12% in the general population (over 75 years) with severe cases, defined by an aortic valve area <1.0 cm² and an aortic mean gradient >40 mmHg, in up to 3.4%.^2,6 The prevalence of infrarenal AAA is around 5% among the elderly (over 75 years). ⁷ Currently, effective simultaneous management of AS and infrarenal AAA is poorly described in literature and remains unclear. ⁴

Due to the association of lower early mortality and device improvements with EVAR, it has become the preferred treatment for AAA compared to open repair; 1.6% vs 5.2%, respectively.^5,8 Evidence has also proven that TAVI restores normal aortic valve function, with lower incidences of peri-operative mortality, paravalvular leakage, patient-prosthesis mismatch and atrioventricular blockage compared to surgical AVR, not only in high risk patients.^9–11

A simultaneous TAVI and EVAR approach was selected following a thorough examination of associated advantages and disadvantages compared to a sequential approach. A single-stage procedure was considered less invasive with a low peri-operative complication risk. The risk of vascular complications was considered reduced by the use of the same access site (no redo groin incision into scar tissue in a subsequent intervention),^3,5 AAA rupture was considered less likely with EVAR protection of the AAA with anticipated increased blood pressure after prosthetic valve implantation, ¹² and the likelihood of reduced post-operative hospital stay. Conversely, the team was aware of the increased operative time, contrast dose and radiation exposure required for a simultaneous approach.

There is currently no consensus regarding the choice between general or local anaesthesia for simultaneous TAVI and EVAR. Our multi-disciplinary team considered the estimated procedural duration of a simultaneous approach, requirement for strictly controlled blood pressure, patient’s high peri-operative risk, feasibility of a percutaneous access, patient collaboration and anaesthesiologist support for peri-operative haemodynamic monitoring. Local anaesthesia was preferred, but was considered dependent upon the patient’s symptomatic status following TAVI. Currently, there are 9 reported single-stage approaches with simultaneous TAVI and EVAR procedures available in literature,^3,13–20 with general anaesthesia specified in 7 cases and unspecified anaesthesia approaches in 2 cases (Table 1). Our case report seems to be the first simultaneous TAVI and EVAR, performed under local anaesthesia.

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Table 1.

Review of EVAR and TAVI Cases Currently Available in Literature.

Author	Year of Publication	Type of Article	Number of Patients (n)	Type of Anaesthesia	Type of Access	Simultaneous Repair	Days of Hospitalization
Yammine et al. 12	2021	Case series	1	NR	P	Y	5.2 (average)
			1	NR	P	Y
			1	NR	P	Y
			1	NR	S	Y
			1	NR	S	Y
Koutsias et al. 4	2020	Case series	1	General	NR	Y	10
			1	General	S	Y	8
Mauri et al. 13	2019	Case series	1	General	S	Y	8
			1	General	P	Y	12
Sato et al. 14	2017	Case report	1	NR	S	Y	8
Marchi et al. 15	2014	Case report	1	General	P	Y	3
Koudoumas et al. 16	2015	Case report	1	General	P	Y	3
Blinder et al. 17	2015	Case report	1	NR	P	Y	NR
Aluko et al. 18	2015	Case report	1	NR	NR	Y	3
Smith et al. 19	2012	Case report	1	General	S	Y	5

The team was also aware of the need to minimize contrast medium administration during the procedure to avoid contrast-induced nephropathy. Yammine et al reported average contrast volume of 100 mL (50 to 200 mL), ¹³ whereas Koutsias et al and Mauri et al, reported volumes ranging between 350 - 385 mL.^4,14 For our procedure 310 mL were administered and no renal function worsening was observed.

Finally, there is still no agreement about which procedure should be performed first. We chose to perform TAVI first, mainly based on the severity of the AS in the impaired left ventricular systolic function. Further, TAVI first was also considered to reduce any risk of abdominal endograft thrombosis and/or displacement with the passage of the aortic valve device delivery over the AAA endograft. These advantages were considered more important than those associated with performing EVAR first; reduced risk of both AAA rupture from increased blood pressure after prosthetic valve implantation and distal embolization secondary to wire and device manipulation through the AAA.

Conclusions

As the general population ages, the number of patients with multiple cardiovascular diseases requiring specific and complex interventions is expected to increase. This clinical case report emphasized the importance of a multidisciplinary approach to shared, individually tailored operative strategies to treat two cardiovascular diseases with the least invasive combined approach. In our case, a single-stage, TAVI and EVAR with a percutaneous approach under local anaesthesia was effective, with rapid patient discharge.