Novel Cerebral Protection Technique During Right Transcarotid TAVR in Bicuspid Aortic Stenosis and Porcelain Aorta

J INVASIVE CARDIOL 2018;30(11):E129.

Key words: cardiac imaging, computed tomography angiography

Periprocedural stroke related to transcatheter aortic valve replacement (TAVR) is associated with increased morbidity and mortality. Cerebral embolic protection using the Sentinel device (Claret Medical) has demonstrated reduced rates of stroke during TAVR. However, alternative access routes, such as the transcarotid approach, preclude the use of the Sentinel device. We report a case using cerebral embolic protection during right transcarotid TAVR.

Computed tomographic angiography demonstrated a bicuspid aortic valve (Sievers type I), and confirmed heavy aortic calcification and severe bilateral iliac and left subclavian stenosis. The only option for access was the right common carotid artery (CCA). Under general anesthesia, a right CCA cutdown was performed to deliver the 34 mm Evolut R bioprosthetic valve (Medtronic). Neuromonitoring was used perioperatively. A Nav6 distal embolic protection device (Abbott Vascular) was deployed in the mid-segment of the left subclavian artery.  A Spider distal embolic protection device was successfully deployed in the left common carotid artery (Figure 1). For complete protection against cerebral embolism, the distal right CCA was also clamped. At the completion of the case, both embolic protection devices were retrieved. Completion angiography of the great vessels, including the intracranials, demonstrated normal flow with no evidence of vascular injury. Postprocedure inspection of both filters revealed minor embolic debris (Figure 2). The patient awoke from general anesthesia with no neurovascular deficits and was discharged the following day without evidence of adverse clinical events.

From Hartford Hospital, University of Connecticut, Hartford, Connecticut.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. LE Curtis reports personal fees from Edwards Lifesciences. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 8, 2018. 

Address for correspondence: Brett Hiendlmayr, MD, Hartford Hospital, University of Connecticut, 85 Seymour Street, Hartford, CT 06106. Email: bjh02002@gmail.com