Abstract 13212: Prevention of Delayed Coronary Obstruction Following Transcatheter Aortic Valve Replacement Using Intravascular Ultrasound and "Modified" Snorkeling Stent Technique

Introduction: Coronary obstruction (CO) is a potentially fatal complication that can occur after transcatheter aortic valve replacement (TAVR). Here we report a successful management of a TAVR patient at risk of delayed CO using intravascular ultrasound (IVUS) and a "modified" snorkeling stent technique.

Case presentation: An 88-year-old woman presented with severe symptomatic aortic stenosis. Despite the left coronary artery (LCA) being not low, a Multidetector Computed Tomography scan identified a relatively long leaflet of the left coronary cusp (LCC) and a calcified nodule on the cusp (Figure 1A), indicating a high CO risk. A transfemoral TAVR was conducted using a 26mm Evolut FX (Medtronic, IL, USA) protecting the LCA with a 6-F Judkins left (JL) 4.0 guiding catheter, a 0.014 inch coronary guide wire, and a guide-extension catheter. Upon reaching the point of no recapture, LCA blood flow was maintained, and hemodynamics was stable. However, IVUS revealed the calcified nodule on the LCC was close to the left main (LM) ostium (Figure 1B), indicating a high risk of delayed CO.We continued and completed the prosthesis deployment protecting the LCA. Following the deployment, We introduced another guiding catheter (6-F JL3.5) into the prosthesis and engaged it with the LCA via the prosthesis frame, utilizing a double-guiding catheter technique. Subsequently, we placed a coronary stent from the LM to the prosthesis (Figure 1C). After the TAVR procedure, we verified that a JL3.5 catheter could easily engage the implanted coronary stent (Figure 1F). This "modified" snorkeling stent technique appears feasible and provides easier coronary access compared to the "Chimney" snorkeling stent technique.