Enabling Transfemoral TAVI Through a Hostile Abdominal Aortic Anatomy and a Migrated Mesenteric Stent Fragment: Review of the Literature and a Case Presentation

Figure 1. Transthoracic echocardiographic evaluation of aortic valve and cardiac function. (A) Continuous-wave Doppler assessment of aortic valve stenosis. (B) Aortic valve aspect (PLAX view). (C) Severe pulmonary hypertension. (D,E) Myocardial function assessment using LVEF and LV longitudinal strain.

Figure 2. Coronary angiography revealing two-vessel coronary artery disease with LAD subocclusion (A), 90% stenosis of LCx (B), and hypoplastic RCA (C).

Figure 3. Aortography revealed: (A) severe atherosclerotic disease of the abdominal aorta with moderate infrarenal aortic stenosis; (B) patent superior mesenteric artery stent; (C) mobile stent fragment; (D) no significant iliac artery stenosis.

Figure 4. Preprocedural planning computed tomography. (A) Three-dimensional reconstruction of the heavily calcified tricuspid aortic valve. (B) Aortic annular measurements compatible with implantation of a 23-mm balloon-expandable valve. (C) Multiplanar reconstruction of LVOT, STJ, aortic arch and descending thoracic aorta calcification. (D) Assessment of the vascular access route demonstrating extensive calcific atherosclerosis of the abdominal aorta with focal infrarenal aortic stenosis and migrated stent fragment; the iliofemoral vessels were considered suitable for transfemoral access. (E) Multiplanar reconstruction demonstrating the calcified abdominal aorta and in situ SMA stent. (F) Close-up sagittal view demonstrating the in situ SMA stent and migrated stent fragment within the abdominal aorta, and extensive abdominal aortic calcification. (G) Axial CT images demonstrating the in situ SMA stent and the migrated stent fragment within the abdominal aortic lumen. Stent fragment—green arrow; SMA and residual stent—yellow arrow; aortic calcifications—orange arrow. Abbreviations: SMA, superior mesenteric artery; STJ, sinotubular junction; LVOT, left ventricular outflow tract.

Figure 5. Endovascular preparation of the abdominal aorta. (A,B) Aortography demonstrating infrarenal aortic stenosis (7 × 8 mm), the in situ SMA stent (yellow arrows), and the migrated stent fragment (green arrows); (C) balloon angioplasty with a 12 × 40-mm VACS® II balloon, simultaneously enlarging the stenotic aortic segment and displacing the fragment toward the aortic wall; (D) stent fragment apposed to the aortic wall after angioplasty; (E) final aortography demonstrating an enlarged aortic lumen (11 × 12 mm) and stable fragment apposition; (F) schematic illustration of balloon angioplasty and fragment apposition. Abbreviation: SMA, superior mesenteric artery.

Figure 6. Transfemoral TAVI procedure. (A) Advancement of the 14-Fr expandable introducer sheath through the previously treated abdominal aortic segment and past the stent fragment apposed to the aortic wall; (B) positioning and deployment of the 23-mm balloon-expandable transcatheter aortic valve; (C) final aortographic assessment following valve implantation.

Figure 7. Echocardiographic assessment after TAVI: (A–C). Intraprocedural transesophageal echocardiography following valve implantation, demonstrating appropriate prosthetic valve position and function with trivial paravalvular regurgitation; (D) transthoracic Doppler echocardiography at 1-month follow-up demonstrating preserved prosthetic valve hemodynamics; (E–H) transthoracic echocardiographic assessment at 2-year follow-up, demonstrating preserved left ventricular systolic function and stable transcatheter valve function with low transprosthetic gradients.