Simultaneous Transcatheter Aortic Valve Implantation and Endovascular Aneurysm Repair for Severe Aortic Stenosis and Symptomatic Abdominal Aortic Aneurysm: Mini Review

Introduction

Patients with severe aortic stenosis (SAS) may concomitantly present abdominal aortic aneurysm (AAA) in 6% of cases. ¹ Aortic valve replacement surgery, performed alone, increases the risk of AAA rupture. ² Currently, recommendations for the treatment of these patients are not defined, making their approach a challenge. Transcatheter aortic valve implantation (TAVR) and endovascular abdominal aortic aneurysm repair (EVAR), in the same procedure, have been reported as a treatment alternative, due to the high success rate of the procedure and the hospital stay reduced.^3,4 We present the case of a 77-year-old man with SAS, infrarenal AAA and left common iliac artery aneurysm, successfully treated with TAVR and EVAR in the same procedure. We also present a review of published cases, with similar characteristics.

Case report

A 77-year-old male patient, with arterial hypertension, dyslipidemia, stage III chronic renal failure and previous coronary revascularization surgery, had been experiencing dyspnea and angina with moderate exertion for a year. On physical examination, he presented a 3 +/4 + systolic murmur in the aortic focus, a pulsatile mass at the abdominal level, and symmetrical peripheral pulses.

The analyzes showed hemoglobin 11.76 mg/dl, without any other alteration. The electrocardiogram showed sinus rhythm, narrow QRS complexes, no conduction disorders, and signs of left ventricular overload. The echocardiogram revealed a left ventricular ejection fraction of 56%, calcified aortic valve with severe aortic stenosis (maximum velocity: 4.36 m/s and mean gradient: 48 mmHg) and moderate aortic insufficiency. The angiotomography of the abdominal aorta showed an infrarenal abdominal aortic aneurysm with diameters of 54 × 42 mm (Figure 1), without calcification or hematomas; in addition, aneurysm of the left common iliac artery (diameters of 29.9 × 25 mm) and dilation of the right common iliac artery (diameter: 11.7 × 9 mm). On cardiac catheterization, the right coronary artery did not have stenosis, the anterior descending and circumflex arteries were occluded, the bridges from the left internal mammary artery to the anterior descending artery and the bridge from the aorta to the marginal branch were patent, without stenosis. CT angiography of the thoracic aorta showed a trileaflet aortic valve, with mild calcification, an aortic annulus with a perimeter of 82.23 mm (Figure 2) and a sinotubular junction with moderate calcification. The calculation of mortality risk, according to the STS score (4.18), was moderate.

OPEN IN VIEWER

Figure 1.

Angiotomography of abdominal aorta, infrarenal abdominal aortic aneurysm, (neck diameter: 19.8 × 22.4 mm, maximum diameter: 54 × 42 mm), left iliac artery aneurysm (diameter: 29.9 × 25 mm).

OPEN IN VIEWER

Figure 2.

Angiotomography of the thoracic aorta, aortic ring (perimeter = 82.23 mm) with mild calcification, right coronary sinus with moderate calcification at the cusp level, sinotubular junction with moderate calcification.

The multidisciplinary team recommended performing TAVR and EVAR in the same intervention. The procedure was performed under general anesthesia, with bilateral femoral arterial percutaneous access and transesophageal echocardiogram. Initially, an Evolut-R No. 29 valve was implanted, then embolization of the right internal iliac artery was performed with two 5 × 8mm coils and finally a 23 × 16 × 145 mm Endurant II bifurcated abdominal endoprosthesis was placed, with a 16 × 10 × 124 mm lateral branch for the iliac artery. Left common iliac artery and two extensions of 16 × 16 × 93 mm and 16 × 20 × 124 mm to cover the common iliac artery and part of the right external iliac artery. The success of the procedures was confirmed by angiographic and echocardiographic controls. No complications were recorded. The patient was discharged on the fifth postoperative day. At 6 months of follow-up, the angiotomography of the abdominal aorta and the echocardiogram confirmed the persistence of the procedure’s success.

Discussion

Currently, the treatment strategies for patients with Severe Aortic Stenosis and Abdominal Aortic Aneurysm indicate, as a primary intervention, aortic valve replacement surgery, and as a secondary option, surgical treatment of the AAA, or in the same procedure, a combination of TAVR (Transcatheter Aortic Valve Replacement) and EVAR (Endovascular Aneurysm Repair). Isolated aortic valve replacement surgery could potentially increase the risk of AAA rupture or dissection due to an elevation in blood pressure. ⁵ Conversely, performing TAVR and EVAR through the common femoral artery reduces the risk of vascular complications, including bleeding, which might occur if both procedures were conducted at separate times. Hence, to minimize the risk of complications, some researchers have proposed simultaneous endovascular treatment for SAS and AAA, utilizing TAVR and EVAR.^6–9

In a review of the literature, we discovered 19 case reports of patients with SAS and AAA who were treated simultaneously with TAVR and EVAR. These reports encompassed a total of 19 patients, of whom 17 were male (87%). The median age was 80 years (ranging from a minimum of 67 to a maximum of 91), and 5 patients had a history of previous cardiac interventions, with coronary revascularization surgery being the most frequent. In most cases, the indication for intervention was symptomatic SAS. In all cases, femoral artery access was utilized. For 13 patients (81%), TAVR was conducted first, followed by EVAR, while in 3 patients, the order was reversed. All procedures were successful, and no complications arose. A summary of all published cases can be found in Table 1.

OPEN IN VIEWER

Table 1.

Summary of Published Cases of Patients With Simultaneous Endovascular Treatment of Aortic Valve Pathology and Abdominal Aortic Aneurysm.

Case #	Age/sex	Previous cardiac interventions	Cardiac parameters				Abdominal aneurysm parameters			First procedure	Access site	EVAR parameters			Procedural time (min)	Follow-up complications
			MG	AVA	Vmax	EF (%)	Location	Diameter (mm)	Length (mm)			Type	Size (mm)	Length (mm)
Our case	77/M	CABG (2002)	48	NM	4.36	56	Infrarenal	54	105	TAVR	Femoral bilateral	Evolut-R	23 × 16	145	NM	None
1 3	79/W	None	42	0.8	NM	60	Infrarenal	64	NM	TAVR	Femoral bilateral	NM	NM	NM	261	None
2 3	78/M	None	61	0.4	5.06	NM	Infrarenal	53	NM	NM	Femoral right	Endologix, irvine, CA	25 × 16	80 × 40	NM	None
3 10	86/M	None	67	0.78	NM	NM	Infrarenal	55	NM	NM	Femoral left	NM	25 × 120 × 16	28 × 28 × 95	138	None
4 5	78/M	CABG (2001)	50	0.8	4.6	50	Infrarenal	60	58	TAVR	Femoral bilateral	Bifurcated endurant endoprosthesis	28 × 16	166	NM	None
5 10	88/M	PCI (2009)	63	NM	5.1	65	Infrarenal	66	62	EVAR	Femoral bilateral	NM	NM	NM	NM	None
6 5	83/M	None	105	NM	5.5	NM	Infrarenal	57	NM	TAVR	Femoral bilateral	W.L. Gore & associates	26 × 14.5	180	138	None
7 11	91/W	None	36	0.4	NM	64	Infrarenal	45	NM	EVAR	Femoral bilateral	Cook Zenith	NM	NM	NM	None
8 12	74/M	None	43	0.8	NM	35	Infrarenal	5	NM	TAVR	Femoral bilateral	Ovation	20	NM	NM	None
9 13	67/M	None	NM	NM	NM	NM	Infrarenal	NM	NM	TAVR	Femoral bilateral	Primer abdominal	NM	NM	NM	NM
10 14	75/M	None	48	0.6	5.3	N	Infrarenal	5.1	NM	TAVR	Femoral bilateral	Cook Zenith	NM	NM	NM	NM
11 15	85/M	NM	88	0.8	NM	NM	Infrarenal	71.4	147	TAVR	Femoral bilateral	W.L. Gore & associates	NM	NM	NM	NM
12 16	80/M	None	46	0.9	NM	55	Infrarenal	68	70	TAVR	Femoral bilateral	W.L. Gore & associates	NM	NM	NM	NM
13 17	83/M	CABG	49	0.8	3.1	35	Infrarenal	55	NM	TAVR	Femoral bilateral	NM	NM	NM	NM	None
14 18	80/M	Multiple procedures for aneurysms	11	0.8	2.3	20	Infrarenal	100	95	TAVR	Femoral bilateral	NM	NM	NM	NM	None
15 19	79/M	None	46	0.7	NM	60	Infrarenal	60	123	TAVR	Femoral bilateral	Cook Zenith	28	111	NM	None
16 20	83/M	NM	27	0.5	NM	35	Infrarenal	5.1	NM	TAVR	Femoral bilateral	Cook Zenith	36	130	NM	None
17 21	82/M	None	71	.88	5.8	40	Infrarenal	70.2	NM	EVAR	Femoral left	Edwards-SAPIEN XT	NM	10	NM	None
18 22	88/M	None	87.2	NM	5.72	50	Infrarenal	NM	60	TAVR	NM	NM	NM	NM	NM	None
19 21	85/M	Peacemaker	54	5.3	0.8	NM	Infrarenal	100	35	TAVR	Femoral bilateral	Cook Zenith	26	20 × 56	120	NM

Yammine H et al, in a retrospective analysis of 5 cases, suggest that simultaneous treatment with TAVI (Transcatheter Aortic Valve Implantation) and EVAR is safe, even for elderly, high-risk patients. ²³ Yu Sato et al emphasize that a single-stage endovascular treatment for both pathologies reduce the risk of AAA rupture, perioperative complications, and hospital stays. They also state that while performing TAVI first may increase the risk of AAA rupture, distal embolization, and aortic dissection since TAVI needs to pass through the AAA, the use of long introducers currently allows safe crossing of the AAA, reducing the risk of rupture and AAA injury. ²⁴ Additionally, the strategy of conducting TAVI before EVAR diminishes the risk of endoprosthesis deformation, thrombosis, or migration. However, it should also be known that patients undergoing TAVR have a higher risk of arrhythmia, which could be an obstacle to proceeding with EVAR. Likewise, when there is severe calcification and tortuosity of the iliofemoral arteries, EVAR is not possible, but TAVR could be performed with alternative approaches.

The option of simultaneous treatment through TAVR and EVAR necessitates the collaboration of a multidisciplinary team capable of individualizing and meticulously analyzing each case, planning the technical aspects of each procedure, and executing optimal TAVR and EVAR techniques, all with the aim of achieving a successful procedure and significant clinical benefit.^15,25 In conclusion, we regard the simultaneous endovascular approach to both pathologies as a promising treatment alternative for selected patients with severe aortic stenosis and abdominal aortic aneurysm Figure 3.

OPEN IN VIEWER

Figure 3.

Result after completion of endovascular aneurysm repair of abdominal aorta that guarantees a satisfactory proximal seal.

Conclusions

We present a review of 19 cases, as well as our own clinical case, of patients at high surgical risk, with severe aortic stenosis and abdominal aortic aneurysm treated successfully, with transcatheter aortic valve implantation and endovascular treatment of abdominal aortic aneurysm simultaneously. We highlight the need to conduct randomized clinical trials in this patient population.

Supplemental Material