Symptomatic AS and AAA are critical clinical conditions, increasingly more prevalent with aging of the population. TAVR is a treatment of choice in high risk and inoperable patients with symptomatic severe AS, who are often elderly. A continuous increase in the number of TAVR procedures-per-year is expected due to the increasingly robust evidence that TAVR is advantageous in the population with non-increased surgical risk.
Our ‘tailored’ interventional approach has planned an endovascular correction of the AAA as the first step, followed by a ‘staged’ TAVR. The AAA was treated first because was it considered strategically better in the presence of severe AS in stable clinical conditions. Moreover the potential elevation of the systolic arterial pressure after TAVR might provoke enhanced strain at the AAA wall increasing the risk of rupture. During the EVAR procedure all the material needed to proceed to an ‘urgent’ aortic valvuloplasty or TAVR if necessary was available and ready.
The proposed treatment was effective in all treated patients, offering the resolution of both problems through totally percutaneous treatment in patients with a significant high risk for both mortality and vascular complications. The risk of acute kidney injury is reduced compared to simultaneous procedures because the total amount of contrast agents used overall is spread among two different procedures after an adequate time of recovery.
The main clinical, technical and procedural considerations of TAVR procedure in this case series were:
Transfemoral access into the bifurcated endoprosthesis was feasible in 100% of patients
The use of highly supportive stiffer guides (or buddy wire technique) to overcome the tortuosity of the iliac-femoral approaches should be considered;
The introducer advancement under fluoroscopic guidance and through-and-through wire technique is strongly recommended in the presence of tortuosity;
The strategy to protect the main vascular access must be personalized choosing between the ipsilateral femoral approach or the radial (or omeral) approach;
The total amount of contrast medium administered to patients should be carefully monitored;
The procedures should always be conducted with as much ‘contrast zero ‘ methods as possible.
Define a delay time between EVAR and TAVR according to the clinical status, the age and the co-morbidities of patients even in the presence of clinical stability, is highly debated.