“Roundabout” Bailout Stenting for Subacute Right Coronary Artery Obstruction After Self-Expandable Transcatheter Aortic Valve Replacement

Figures

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  Visual Summary. Timeline of Case Presentation AVB = atrioventricular block; CT = computed tomography; RCA = right coronary artery; TAVR = transcatheter aortic valve replacement.

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  Figure 1. Preprocedural Computed Tomography Measurements (A to E) The anatomical features of the aortic valve were deemed suitable for implantation of a 26-mm Evolut FX valve. The overall risk of coronary artery obstruction was estimated to be low based on several parameters: (E) SoV diameters, (G) RCA height, (I) cusp height, and (J) calcium volume of the right coronary leaflet. However, (M) the VTC distance was measured at 3.4 mm, which was the only parameter below the established safety cutoff. Asc. Ao = ascending aorta; LC = left coronary; LCA = left coronary artery; LVOT = left ventricular outflow tract; NC = noncoronary; RC = right coronary; RCA = right coronary artery; SoV = sinus of Valsalva; STJ = sinotubular junction; VTC = valve-to-coronary.

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  Figure 2. Angiography During Transcatheter Aortic Valve Replacement and Percutaneous Coronary Intervention (A) Immediately after transcatheter aortic valve replacement, aortic angiography demonstrated opacification of both the RCA and RCS. (B) However, angiography after the patient's sudden deterioration failed to visualize either structure. (C and D) Selective contrast injection from the NCS via a guiding catheter partially opacified the RCS. (E and F) Based on this finding, a guidewire was introduced through the NCS, successfully crossing the RCA. (G and H) Final coronary angiography showed TIMI flow grade 3. NCS = noncoronary sinus; RCA = right coronary artery; RCS = right coronary sinus.

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  Figure 3. Intravascular Ultrasound Before and After Stent Implantation (A to C) IVUS demonstrating the presence of a thrombus and native valve tissue within the right coronary sinus. (D to F) After implantation of the first zotarolimus-eluting stent (ZES), IVUS showed compression of the stent by the transcatheter heart valve. (G to I) Subsequent IVUS imaging after the placement of a second overlapping ZES and postdilation with a 5.0-mm noncompliant balloon confirmed the restoration of an acceptable luminal area. IVUS = intravascular ultrasound.

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  Figure 4. Schematic Representation of the Ipsilateral and Roundabout Approaches (A) Sequestration of the RCS leads to reduced sinus flow and thrombus formation. Red arrows in (B) to (E) indicate access routes: arrow 1 represents the ipsilateral approach and arrow 2 represents the roundabout approach. (B and D) The ipsilateral approach failed because of obstruction by the transcatheter heart valve and native aortic valve leaflets, which prevented coronary access. (C and E) The roundabout approach, tracking along the outer frame of the transcatheter heart valve from the NCS to the RCS, successfully enabled guidewire crossing into the RCA. LCA = left coronary artery; LCS = left coronary sinus; NCS = noncoronary sinus; RCA = right coronary artery; RCS = right coronary sinus.

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  Figure 5. Computed Tomography and 3-Dimensional Reconstruction Images at 6-Month Follow-Up (A to D) At 6 months, the stents were positioned at the proximal RCA via a route from the NCS through the transcatheter heart valve strut above the RCS. (B to E) Detailed computed tomography assessment demonstrates that commissural alignment was successfully achieved and considered favorable. (E and F) The roundabout approach is clearly visualized through the 3-dimensionally reconstructed images (reconstructed using Viewtify, Sciement). Abbreviations as in Figure 4.