Figure 1.. Cardiac computed tomography scan showing a virtual 23 mm Sapien3UR valve within the degenerative 25 mm Magna Ease surgical aortic valve replacement (SAVR). Virtual-valve-to-coronary distance to the left main stem is shown in longitudinal (A) and short axis (B) slices, indicating a high risk for coronary obstruction after transcatheter aortic valve replacement. C, Short axis Hockey Puck minimal intensity projection of the SAVR showing dense, confluent, leaflet calcification of all cusps, making the patient ineligible for leaflet modification techniques. Red dot=left cusp, green dot=right cusp, yellow dot=noncoronary cusp. LCA indicates left coronary artery; LCC, left-coronary cusp; NCC, noncoronary cusp; and RCC, right-coronary cusp.
Figure 2.. Key procedural steps. Fluoroscopy (left-sided) and graphic representations (right-sided) showing (A and A′) stent-and-stingray technique for retrograde intentional coronary artery exit. The retrograde guidewire (arrowhead) exits the Stingray (asterisk) and perforates the left main to the pericardium. This defines the graft distal anastomosis. B and B′, Electrosurgical guidewire exit of the aortic root (asterisk) to the pericardium. The location of the exit defines the graft proximal anastomosis. C and C′, VECTOR guidewire rail (black arrowhead) is established. The retrograde guidewire is externalized (interrupted arrows) through the transaortic guide catheter (asterisk) and is used to deliver (D and D′) the stent graft (yellow arrowhead) antegrade from the aorta (black arrowhead) to the left main (asterisk). LCC indicates left-coronary cusp; and LMCA, left main coronary artery.
Figure 3.. Transcatheter aortic valve replacement (TAVR) and computed tomography (CT) after ventriculo-coronary outward navigation and reentry (VECTOR). A, Before TAVR implantation, the native left main stent (asterisk) is seen within the surgical aortic valve replacement (SAVR) valve frame post (yellow arrowhead), and the VECTOR extra-anatomic bypass (white arrowhead) cephalad. B, During valve deployment, the native left main stent is longitudinally compressed by the displaced left-coronary cusp (LCC) leaflet (white arrowhead). C, Aortic root angiography showing a lucent line (white arrowhead) created by the LCC leaflet between valve frames and left main ostium/stent. The lucent line is in contact with the stent and extends to the sino-tubular junction, indicating coronary obstruction. D, Maximum-intensity-projection CT from postprocedure day 1 shows occlusion of the native left main stent (white arrowhead), which otherwise might allow competitive flow.
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Bruce et al. (2026) studied this question.
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