Key result
Femoral-to-carotid shunting maintains cerebral perfusion during carotid TAVR after severe test-occlusion NIRS drop.
Why the study?
Carotid access is an alternative for TAVR in patients with prohibitive transfemoral anatomy, but it may cause cerebral hypoperfusion in the presence of impaired intracranial collateral circulation.
Does femoral-to-carotid arterial shunting prevent cerebral hypoperfusion and neurologic complications during carotid-access TAVR in a patient with moyamoya-pattern vasculopathy?
Case Report (n=1)
Does femoral-to-carotid arterial shunting prevent cerebral hypoperfusion and neurologic complications during carotid-access TAVR in a patient with moyamoya-pattern vasculopathy?
Real-time cerebral near-infrared spectroscopy combined with femoral-to-carotid arterial shunting offers a novel cerebral protection strategy to prevent hypoperfusion during carotid-access TAVR in patients with moyamoya-pattern vasculopathy and compromised collateral reserve.
Should not yet change cerebral protection practice in carotid-access TAVR; leaves open femoral-to-carotid shunting utility in moyamoya vasculopathy.
BACKGROUND: Carotid access is an alternative for transcatheter aortic valve replacement (TAVR) in patients with prohibitive transfemoral anatomy, but it may cause cerebral hypoperfusion with impaired intracranial collateral circulation. CASE SUMMARY: A 67-year-old woman with symptomatic severe aortic stenosis, extensive comorbidities, and unsuitable transfemoral access underwent TAVR. Neuroimaging demonstrated moyamoya-pattern intracranial vasculopathy with limited collateral reserve. During left carotid exposure, test occlusion caused a >50% decline in cerebral near-infrared spectroscopy despite blood pressure augmentation. A femoral-to-carotid arterial shunt was established to maintain cerebral perfusion. A 26-mm self-expanding Evolut FX+ valve was successfully implanted via left carotid access, with excellent hemodynamics and no neurologic complications. DISCUSSION: This approach demonstrates a novel cerebral protection strategy for selected patients with compromised cerebrovascular reserve. TAKE-HOME MESSAGES: Carotid-access TAVR in moyamoya-pattern vasculopathy carries hypoperfusion risk. Real-time near-infrared spectroscopy may detect intolerance to carotid clamping, while femoral-to-carotid shunting may offer cerebral protection.
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Mourad et al. (2026) conducted a case report in Symptomatic severe aortic stenosis with moyamoya-pattern intracranial vasculopathy (n=1). Femoral-to-carotid arterial shunting during left carotid-access TAVR (26-mm Evolut FX+ valve) was evaluated on Successful valve implantation and absence of neurologic complications. Femoral-to-carotid arterial shunting during carotid-access TAVR maintained cerebral perfusion after test occlusion caused a >50% NIRS decline, enabling implant without neurologic complications.
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