An 89-year-old female patient requiring surgery for colorectal cancer also suffered from severe calcified aortic valve stenosis (aortic mean gradient = 59 mmHg, aortic area = 0.4 cm²) and left main significative stenosis, which were contraindications for her cancer surgery. Two weeks before valve implantation, she underwent multiple coronary vessel stenting for unstable angina. Discussions among the local heart team led to the proposition of TAVR to treat the severe aortic stenosis, with easy access to the coronary ostia in the future being a primary concern.
Aortic root dimensions and the access site were precisely measured using computed tomography (CT) angiography, with the aortic annulus having a perimeter of 67 mm and an area of 320 mm². While heavy iliac and femoral calcifications with multiple staggered stenosis contraindicate a femoral route, the Doppler and CT studies of supra-aortic vessels did not show any abnormalities. The right common carotid artery was free from calcifications, and its internal diameter was 7 mm at puncture level. The implantation of an S-size ACURATE neo™ aortic valve (Boston Scientific, MA, USA) via the right carotid artery was collegially retained by the local heart team. After obtaining the patient’s consent, the TAVR procedure was performed according to local standard protocol in a hybrid operating room. Intravenous heparin was administrated to maintain an activated clotting time of ≥250 s. The patient was under dual platelet therapy for a recent previous coronary stent implantation. Surgical access for TAVR was performed under general anesthesia with a fast-track approach. A 5 Fr pigtail was advanced into the aortic root using a left radial approach. Through a 4 cm right cervical incision (Figure 1A), the right common artery was exposed. The stenotic aortic valve was then crossed using a straight-tip guide wire and an Amplatzer left 1 diagnostic catheter (Terumo Medical, Somerset, NJ). The straight-tip guidewire was then replaced with a pre-shaped extra-stiff Safari XS (Boston Scientific, MA, USA) in the left ventricle. An iSLEEVE™ (Boston Scientific, MA, USA) expandable sheet was cautiously advanced into the ascending aorta (Figure 1B). Given the heavy annular calcification, we performed a 22 mm valvuloplasty using a noncompliant balloon (Cristal balloon, BALT, Montmorency, France).
Prothesis placement was performed in the standard fashion, and the up-to-down deployment was satisfactory—with enhanced stability because of the short distance between the arterial carotid access and the aortic annulus (Figure 1C). After a satisfactory angiogram (Figure 1D), the iSLEEVE™ introducer was removed, and the common carotid artery was surgically purged and repaired using a 6–0 polypropylene running suture. Echocardiography confirmed the absence of paravalvular leak, and the mean prosthetic gradient was 7 mmHg. After continuous ECG monitoring, the patient was discharged home on the third postoperative day, per our local practice. Based on the Valve Academic Research Consortium (VARC 2) criteria, we recorded no complications.