Aortoiliac calcification hindering cardiac interventions: A case for intravascular lithotripsy

Figures

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  Fig. 1. Transthoracic echocardiography (TTE). 2d TTE with doppler showing severe aortic stenosis (peak/mean gradient 83/49 mmHg, AVA of 1.0 sq cm) and mild-moderate aortic regurgitation

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  Fig. 2. Left heart catheterization (LHC). LHC showing left main artery 60% stenosis, The IFR was noted to be 0.82 and minimal lumen area (MLA) 5.4 mm2, proximal left anterior descending artery 50% stenosis, ostial diagonal 80% and proximal left circumflex artery 60-70% stenosis. Repeat angiogram post Impella assisted dual kissing (DK) crush percutaneous coronary intervention (PCI), LM to LAD and LM to LCX showing improved flow.

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  Fig. 3. Aortoiliac disease. Abdominal aortic angiogram (left) demonstrating over 90% stenosis of the aorta and significant reduction of the lumen between the origin of the superior mesenteric artery and right renal artery due to calcified plaque. CT aortogram with bilateral iliac run offs (right) demonstrating focal chunky abdominal aortic calcification between SMA and Right Renal Artery and reduction of the lumen to 4×10 mm, and severe bilateral iliac stenosis.

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  Fig. 4. Intravascular lithotripsy. Two Shockwave intravascular lithotripsy (IVL) M5 7×60 mm catheters, 1 from each groin advanced into the aorta at the site of stenosis. IVL and balloon angioplasty of the aorta performed and residual stenosis of about 40% from 90% but the lumen significantly improved.

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  Fig. 5. Transcatheter aortic valve replacement (TAVR). Staged TAVR after 3 weeks with Edwards SAPIEN 26 mm S3 valve while securing left main artery. Aortogram post TAVR showing successful intervention and no flow obstruction. Abdominal angiogram of aorta shows improvement in aortic calcification allowing for insertion of wide bore sheath required for TAVR.