Transcaval transcatheter aortic valve implantation in bicuspid aortic valve: A step‐by‐step procedural guidance

Figures

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  Figure 1. Pre‐TAVI CT evaluation. Pre‐TAVI CT showed Type‐1 bicuspid aortic valve (L−R) (A) and invalid transfemoral access (B). The ideal cava‐aorta puncture site was defined in the nearest location between IVC and aorta without calcification in the aortic wall (C). The upper part of L3 was defined as the bone marker for a puncture (D). The angle of the perpendicular puncture was measured to predict the long axis and short axis projections (E). The distances of the puncture site to renal arteries and iliac bifurcation were measured to ensure enough length for an emergent stent implant (F). CT, computed tomography; IVC, inferior vena cava; TAVI, transcatheter aortic valve implantation

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  Figure 2. Puncture system. The puncture system was equipped outside to inside by a 6‐F 55‐cm JR4 guiding catheter, NaviCross microcatheter, Piggyback 0.035‐inch wire convertor, Astato XS 0.014‐inch coronary guidewire.

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  Figure 3. Schematic illustration of puncture technique. Simultaneous angiography is performed in long axis projection with two pigtails, which are higher in the artery and lower in the vein (A). The perpendicular puncture site is defined in both long (B) and short axes (C). Puncture is performed in the short axis (D). The snare system takes the guidewire toward the descending aorta (E). The balloon‐expandable sheath is introduced via stiff wire (F).

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  Figure 4. Puncture technique under fluoroscopy (A‐F)

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  Figure 5. Shunt occlusion. After aortic root angiography showed the functional result of Sapien 3 (A), an Amplatzer Duct Occluder was deployed to occlude the aorto‐caval access (B). Final angiography showed complete occlusion (C).

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  Figure 6. Perpendicular puncture. A perpendicular puncture ensures safety (A). An oblique puncture can cause aortic injury (B).

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  Central Illustration 1. Transcaval TAVI. The ideal anatomic selection, perpendicular puncture with predicted projection and four‐component equipment, and complete shunt occlusion ensure the successful TAVI in the transcaval approach. THV, transcatheter heart valve.