By Rainer Moordorf
TAVI has become an alternative approach to medical management or surgical aortic valve replacement for the treatment of severe aortic stenosis in surgically inoperable or high-risk patients. The procedure is mostly performed via a transfemoral or a transapical approach. A relevant number of patients with severe aortic stenosis also suffer from symptomatic carotid artery disease. Rainer Moosdorf describes a new combined surgical approach that his centre has developed for patients in this subgroup.
In a patient with high-grade stenoses of both the internal carotid arteries and the right vertebral artery, who had already experienced a stroke without major sequele, a severe aortic stenosis was detected during the preoperative evaluation for carotid endarterectomy. The patient was therefore sent to our department and we decided to go for a combined intervention between heart and vascular surgeons.
The right carotid artery was first reopened under local anaesthetic and then after intubation and induction of general anaesthesia, endarterectomy of the left carotid artery was performed. Thereafter, an 8mm Dacron prosthesis was connected to the right common carotid artery in an end-to-side fashion and a sheath introduced into it. Via this approach, a self-expanding aortic valve prosthesis (Corevalve, Medtronic) was placed in typical position after predilatation. Importantly, the introducer sheath was not advanced into the carotid artery, so that antegrade bloodflow was maintained during the entire TAVI procedure without further shunting.
In a second case, a severe stenosis was identified in only the left internal carotid artery but a highly significant aortic stenosis was also observed. Therefore, an endarterectomy in the left carotid artery was performed under local anaesthetic before TAVI was performed under a short period of general anaesthesia as previous described.
Both patients showed an uneventful postoperative course without any new neurologic deficits.
For a number of elderly patients with severe aortic stenosis and symptomatic carotid artery disease, the combined approach of carotid endarterectomy and transcarotid TAVI offers a real minimally invasive one-stop treatment. The advantages of this procedure, as developed by our team, are an optimal neuromonitoring during carotid surgery in local anaesthesia and a simple implantation of the catheter-based aortic valve prosthesis via the same access and during an only short period of general anaesthesia. Importantly, as already mentioned above, the introducer sheath for the TAVI must only be advanced into the “Dacron chimney” and not further into the carotid artery to provide a sufficient antegrade flow throughout the whole procedure.
Alternatively, we have also successfully performed a transapical stenting of carotid lesions prior to aortic valve implantation via the same route. In particular, the advancement of wire and sheath into the carotid artery are very straight forward with this approach but it was deemed too risky in these severely diseased patients mentioned above.
Rainer Moosdorf, chairman of the Department for Cardiovascular Surgery, University Hospital Marburg –UKGM, Marburg, Germany