Lithotripsy-assisted transfemoral aortic valve implantation

An 85-year-old man with previous left anterior descending and left circumflex stenting and low left ventricular ejection fraction (35%) developed acute pulmonary oedema because of severe aortic valve stenosis (0.7 cm2). Computed tomography showed bilateral calcific atheromas of both external iliac arteries with circumferential thick calcium plates restricting the lumen diameter to 4.1 mm. The case was refused for surgery and initially discarded for transfemoral aortic valve implantation (TAVI) because of poor vascular access. After a new episode of pulmonary oedema refractory to medical treatment and requiring ultrafiltration, a transfemoral TAVI was attempted. The calcified stenosis of the right external iliac artery was dilated with a 7.0 mm lithotripsy balloon (Shockwave Medical, CA, USA). After six lithotripsy runs, there was good balloon expansion at low pressure (4–6 atm). Gentle twist and push over a Confida wire drove the 18 Fr delivery system of a 29 mm Evolut-R Medtronic valve through the narrowest segment of the iliac artery. After valve deployment half a diamond below the aortic annulus, there was trivial aortic regurgitation with no ruptures or dissections at the access site. Panel A: Computed tomography longitudinal image of the severely calcified right external iliac. Panel B: Multiple cross-sections with near circumferential calcification and thick protruding nodules. Panel C: 3D image of the iliac bifurcation showing severe tortuosity and calcification of both iliac arteries. Panel D: Shockwaves delivered via a 7 mm lithotripsy balloon inflated at 4 atm. Panel E: 18 Fr delivery system of the Evolut-R Corevalve across the calcified segment. Panel F: Final aortogram with no dissection or extravasation.