Internal Endoconduit-Assisted Transfemoral TAVR in a Patient With Severely Diseased Iliofemoral Anatomy

Figures

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  Visual Summary. Overcoming Hostile Vascular Anatomy Using Internal Endoconduit Technique CIA = common iliac artery; EIA = external iliac artery; IIA = internal iliac artery; TAVR = transcatheter aortic valve replacement.

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  Figure 1. CT Angiography of the Left Access Artery Before and After the Internal Endoconduit (A) MIP of the preoperative CT angiogram reveals heavily calcified and severely stenotic iliac and common femoral arteries. The reconstructed cross-sectional images perpendicular to the center line of the left iliofemoral artery demonstrate markedly reduced luminal diameters, ranging from 2.4 to 4.4 mm. (B) MIP of the postoperative CT angiogram demonstrates a stent graft–supported endoconduit along the left iliac and common femoral arteries. Cross-sectional images of the respective portions show marked luminal expansion, with diameters ranging from 6.4 to 7.6 mm, which most likely indicated rupture of the native iliac artery after stent graft deployment and balloon angioplasty. CT = computed tomography; MIP = maximum intensity projection.

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  Figure 2. Impact of Puncture Sites on the VIABAHN (A) More central vs (B) closer to the distal edge. The risk of distal-edge displacement was comparable between sites, whereas distal-edge deformation was higher with puncture at (B).

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  Figure 3. Preplacement of Perclose ProStyle Sutures and ePTFE Apposition at the Sheath Entry Site Two preplaced sutures gathered the ePTFE covering tightly around the entry site, which is expected to facilitate enough hemostasis. ePTFE = expanded polytetrafluoroethylene.

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  Figure 4. Final Iliofemoral Artery Angiography (A) After fastening the prepositioned sutures, trivial access site bleeding persisted. (B) Complete hemostasis was obtained with an additional stent-graft implantation. CFA = common femoral artery; EIA = external iliac artery.