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Descending Aorta Rupture During Transcatheter Aortic Valve Replacement

2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 2 Linguagem: Inglês

10.1161/circulationaha.115.019824

1524-4539

José Agustín, Pilar Jiménez‐Quevedo, Luis Nombela‐Franco, Carlos Almerı́a, José Juan Gómez de Diego, José L. Ayala, Pedro Marcos‐Alberca, P Mahia, Iván J. Núñez‐Gil, Leopoldo Pérez de Isla, Antonio Fernández-Ortı́z, Carlos Macaya,

Aortic Disease and Treatment Approaches

HomeCirculationVol. 133, No. 2Descending Aorta Rupture During Transcatheter Aortic Valve Replacement Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBDescending Aorta Rupture During Transcatheter Aortic Valve Replacement Jose Alberto de Agustin, MD, PhD, Pilar Jiménez-Quevedo, MD, PhD, Luis Nombela-Franco, MD, Carlos Almeria, MD, PhD, José Juan Gomez de Diego, MD, PhD, Jose Luis Rodrigo, MD, PhD, Pedro Marcos-Alberca, MD, PhD, Patricia Mahia, MD, PhD, Ivan Javier Nuñez-Gil, MD, PhD, FESC, Leopoldo Perez de Isla, MD, PhD, FESC, Antonio Fernandez-Ortiz, MD, PhD and Carlos Macaya, MD, PhD, FESC Jose Alberto de AgustinJose Alberto de Agustin From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Pilar Jiménez-QuevedoPilar Jiménez-Quevedo From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Luis Nombela-FrancoLuis Nombela-Franco From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Carlos AlmeriaCarlos Almeria From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , José Juan Gomez de DiegoJosé Juan Gomez de Diego From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Jose Luis RodrigoJose Luis Rodrigo From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Pedro Marcos-AlbercaPedro Marcos-Alberca From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Patricia MahiaPatricia Mahia From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Ivan Javier Nuñez-GilIvan Javier Nuñez-Gil From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Leopoldo Perez de IslaLeopoldo Perez de Isla From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. , Antonio Fernandez-OrtizAntonio Fernandez-Ortiz From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. and Carlos MacayaCarlos Macaya From Cardiovascular Institute, Hospital Universitario San Carlos, Madrid, Spain. Originally published12 Jan 2016https://doi.org/10.1161/CIRCULATIONAHA.115.019824Circulation. 2016;133:e14–e17A 88-year-old woman with a permanent VDD pacemaker and severe aortic stenosis underwent elective transcatheter aortic valve replacement because of high surgical risk (logistic Euroscore of 35.3%). Aortic valve area was 0.5 cm2, mean gradient was 86 mm Hg, and left ventricular ejection fraction was 64% on transthoracic echocardiography. Aortic annulus sizing was 23.5 and 23.7 mm by transesophageal echocardiography and multidetector computed tomography, respectively. Femoral and iliac arteries evaluated by angiography and computed tomography were straight with mild calcification and had adequate internal diameters. Great tortuosity of the aorta was also observed in computed tomography, with the presence of a double angle in the descending thoracic aorta and a very pronounced curve in the distal part of the aortic arch (Figure 1). The procedure took place via right transfemoral access with the use of a percutaneous closure device. A self-expandable 29-mm Core Valve prosthesis (Medtronic, Inc., Minneapolis, MN) was advanced, encountering a high resistance at the level of the distal part of the aortic arch that precluded the progress. When advancement of the prosthesis was attempted, the delivery system was bent at the level of the first angle in the descending aorta, worsening the angle (Figure 2 and Movie I in the online-only Data Supplement). Shortly after, acute hemodynamic collapse ensued. Aortography was subsequently performed, revealing extravasation of contrast medium from the descending thoracic aorta at the level of the external edge of the proximal angle in the descending aorta seen in computed tomography where the delivery system was bent (Figure 3 and Movie II in the online-only Data Supplement). Transesophageal echocardiography also showed the descending aortic rupture (Figure 4 and Movies III–V in the online-only Data Supplement). An occlusive 250-mm aortic valvuloplasty balloon was quickly inflated distal to the left subclavian take-off to limit active bleeding by the same femoral access. Subsequently, a 31×15 mm stent graft (Gore TAG, WL Gore, Newark, DE) was deployed to cover the leakage site. The stent graft position was verified by angiography, and no endoleak was detected. Hemodynamic status improved after stent deployment. Subsequently, a 26-mm balloon-expandable Edwards-Sapien-3 valve (Edwards Lifesciences LLC, Irvine, CA) was successfully implanted without complications. Repeated aortic injection after the procedure demonstrated no leakage of contrast material outside the aorta (Figure 5 and Movie VI in the online-only Data Supplement). A large bilateral hemothorax was detected by transesophageal echocardiography. Blood transfusion was started, and a chest drainage tube was placed to enable complete evacuation. However, despite aggressive fluid replacement and intravenous injection of high doses of inotropic agents and vasoconstrictors, the patient's hemodynamic status worsened gradually, and she died of refractory hypovolemic shock 2 hours later. Necropsy revealed a large tear of the aortic wall at the level of the proximal angle in the descending aorta covered by the stent graft (Figure 6) and a large hemothorax.Download figureDownload PowerPointFigure 1. Pre-TAVR chest computed tomography. A, Coronal contrast-enhanced CT image showing the great tortuosity with a double angle in the descending thoracic (arrows). B, 3D reconstruction showing kinking of the aorta and a very pronounced curve in the distal part of the aortic arch (arrow). CT indicates computed tomography; 3D, 3-dimensional; and TAVR, transcatheter aortic valve replacement.Download figureDownload PowerPointFigure 2. Fluoroscopy during the advancement of the prosthesis. A high resistance was found at the level of the distal part of the aortic arch (A), and the delivery system was bent at the level of the first angle in the descending aorta, worsening the angle (B).Download figureDownload PowerPointFigure 3. Aortography showing extravasation of contrast medium (arrow) from the descending thoracic aorta at the level where the delivery system was bent.Download figureDownload PowerPointFigure 4. Transesophageal echocardiography. A, Two-dimensional transesophageal echocardiography image showing the rupture of the anterior aortic wall (arrow). B, Color Doppler image showing systolic flow across the site of rupture (arrow). C, Three-dimensional transesophageal echocardiography image showing the tear of the aortic wall (arrow).Download figureDownload PowerPointFigure 5. Fluoroscopy (A) and aortography (B) after stent graft deployment and TAVR, showing no leakage of contrast material outside the aorta. TAVR indicates transcatheter aortic valve replacement.Download figureDownload PowerPointFigure 6. Necropsy demonstrated a large tear (arrows) of the aortic wall at the level of the external edge of the proximal angle in the descending aorta covered by the stent graft.Transcatheter aortic valve replacement has become an established treatment for patients with symptomatic aortic valve disease deemed inoperable or at high risk for conventional surgical aortic valve replacement.1 Although it is a less invasive catheter-based procedure, it is associated with some potentially fatal complications. Acute rupture of the descending aorta is unusual and almost invariably has a lethal outcome.2,3 This complication should be suspected in the case of unexplained hypotension during catheter advancement. In our case, we hypothesize that the aortic rupture at the time the delivery system was advanced was attributable to the presence of an acute angle in the aortic arch that transmitted resistance to the delivery system and kinked the descending aorta in the proximal angle. This case gives further evidence that careful evaluation, selection of the patient candidates, and the approach for transcatheter aortic valve replacement are crucial, and must be discussed on a case-by-case basis, considering the benefit–risk ratio.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.019824/-/DC1.Correspondence to Jose Alberto de Agustín, MD, PhD, Cardiovascular Institute, Hospital Universitario San Carlos, Profesor Martin Lagos s/n, 28040 Madrid, Spain. E-mail [email protected]References1. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363:1597–1607. doi: 10.1056/NEJMoa1008232.CrossrefMedlineGoogle Scholar2. Aminian A, Lalmand J, El Nakadi B. Perforation of the descending thoracic aorta during transcatheter aortic valve implantation (TAVI): an unexpected and dramatic procedural complication.Catheter Cardiovasc Interv. 2011; 77:1076–1078. doi: 10.1002/ccd.22960.CrossrefMedlineGoogle Scholar3. Dahdouh Z, Roule V, Lognoné T, Sabatier R, Grollier G. Aortic arch rupture: an uncommon but fatal complication during transcatheter aortic valve implantation.JACC Cardiovasc Interv. 2013; 6:416–417. doi: 10.1016/j.jcin.2012.08.029.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kaneko U, Hachinohe D, Kobayashi K, Horita R, Shitan H, Kawamura T, Mitsube K, Koshima R and Fujita T (2022) Combined Use of Ultra-Long Sheath and Buddy Wire Technique to Deliver SAPIEN 3 Valve, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2022.01.288, 15:7, (789-790), Online publication date: 1-Apr-2022. Useini D, Beluli B, Christ H and Strauch J (2021) Impact of diverse aortic pathologies on outcomes after transapical transcatheter aortic valve replacement, Journal of Cardiac Surgery, 10.1111/jocs.15516, 36:7, (2240-2246), Online publication date: 1-Jul-2021. Geile J, Doberentz E and Madea B (2020) Rapid development of an iatrogenic aortic dissection following transcatheter aortic valve implantation, Forensic Science, Medicine and Pathology, 10.1007/s12024-020-00219-2, 16:2, (335-339), Online publication date: 1-Jun-2020. Duque Santos Á, Reyes Valdivia A, Gallo González P, González Ferrer E, Ocaña Guaita J and Gandarias Zúñiga C (2018) Descending Aorta Rupture after Transcatheter Aortic Valve Embolization, Annals of Vascular Surgery, 10.1016/j.avsg.2017.11.042, 49, (312.e1-312.e4), Online publication date: 1-May-2018. Kaneko U, Kobayashi K, Hachinohe D, Sumino S, Furugen A, Kawamura T, Doi H and Fujita T (2018) Successful Direct Iliac Transcatheter Aortic Valve Implantation to Overcome Significant Tortuosity of the Thoracic Aorta, Korean Circulation Journal, 10.4070/kcj.2018.0129, 48:10, (949) January 12, 2016Vol 133, Issue 2 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.019824PMID: 27028438 Originally publishedJanuary 12, 2016 PDF download Advertisement SubjectsAngiographyCatheter-Based Coronary and Valvular InterventionsComputerized Tomography (CT)Echocardiography