A 65-year-old man with severe, symptomatic AS was referred to our heart team. The preoperative echocardiography showed a severely degenerated bicuspid AS with a mean gradient of 41 mmHg (LVEF 47%). With an estimated mortality of 10.12% (Euroscore II) based on various severe co-morbidities, the heart-team recommended an interventional aortic valve approach. Because of furthermore severely calcified and stenotic iliac arteries, an approach via left subclavian artery was chosen using a self-expandable valve (Evolut pro+; Medtronic, Minneapolis, Minnesotta, USA).
The procedure was performed in a hybrid operating room under general anesthesia. A transesophageal echocardiography (TEE) probe was inserted for periprocedural valve assessment. Via an incision in the infraclavicular fossa the left subclavian artery (8 mm in diameter) was exposed and an 8 mm Dacron tube was grafted for vascular access. The delivery sheath was introduced into the Dacron tube without passing the artery. By advancing the TAVI prosthesis under fluoroscopy within the subclavian artery an impediment at the level of the vertebral artery was sensed. The prosthesis was retracted and the location radiographically inspected. There was no severe kinking or harm to the vessel detected. Hence, the valve was reinserted and under slight resistance positioned in the annulus. After uneventful deployment of the prosthesis, function was assessed with TEE. It showed a 6 cm floating cylindrical structure in the course of the TAVI-prosthesis (Additional file 1). Suspecting some intravascular damage, a control angiogram was performed, displaying a filling defect of the subclavian artery (Fig. 1). We suspected an intimal tear caused by the valve insertion with subsequent dislocation and fixation in the struts of the TAVI-prosthesis. Since this highly mobile structure was considered to be potentially embolic, we proceeded to surgical extraction via sternotomy. Under CPB a median sternotomy was performed and routine cannulation for cardiopulmonary bypass was initiated. After aortic cross-clamping and cardioplegic arrest, aortotomy was performed. The intraoperative inspection revealed an intimal cylinder of the left subclavian artery nailed by the valve stent into the annulus, subsequently being completely removed (Fig. 2) leaving the correctly implanted TAVI in situ. Postoperatively, valve function (no regurgitation and a mean gradient of 2 mmHg) and blood circulation of the left arm were uncompromised.
Yet, on postoperative day 4 absence of pulsation of the left-sided radial artery occurred. The CTA scan showed a dissection flap in the proximal left subclavian artery and distal contrast loss (Fig. 3). Catheter-based vascular intervention with Fogarty balloon-removal of the dissected intimal flap was performed. Postoperative control revealed return of peripheral pulse on the radial artery (Fig. 4). Further postoperative course was uneventful. The patient presented no new cardiac, vascular or neurologic sequelae at discharge.