H.C.H.

This is a 83 years old male with background Diabetes Mellitus, Hypertension and Ischemic Heart Disease. He was known to have Severe Aortic Stenosis, and was planned for Transcatheter Aortic Valve Replacement after a mutidisciplinary team meeting. Before TAVR procedure, he had Coronary Angiogram done showing severe disease in the LAD. This was intervened first successfully, with 2 drug eluting stents implanted. This procedure itself was uncomplicated.

Echocardiogram done as workup. Findings are as below.
Trileaflet aortic valve. Heavily thickened and calcified all cusps with reduced excursion.Mean PG : 42 mmHgMax PG : 70 mmHgAVA (VTI) : 0.66 cm��Dimensionless index : 0.20
The initial plan was to utilize a new, balloon expandable valve Myval by Meril. It would have been the first use of such valve in our institution.

Coronary Angiogram + PCI in September 2020.

• Left Main Stem : Mild to moderate distal Left Main Stem
• Left Anterior Descending : Severe disease proximal. Further moderate - severe distal mid.
• Left Circumflex Artery : Mild proximal disease. Moderate to severe proximal Obtuse Marginal
• Right Coronary Artery : Mild disease mid and Right Posterior Lateral branch.

2 drug eluting stents size 2.5 x 38 mm and 3.5 x 38 mm were implanted with IVUS guidance.
CAG 7.avi
CAG 24.avi
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He underwent the TAVR procedure on 31st December 2020. Both femoral accesses were utilized, with a 14Fr Python introducer sheath delivered via right femoral artery and 6Fr sheath over left femoral artery for pigtail. The procedure itself was uncomplicated except for short duration of Atrial Fibrilliation post procedure. This was quickly resolved with cardioversion. Patient was discharged well afterwards.
However he presented with worsening right foot pain 2 weeks after, in which became apparent when right foot drop developed. Diagnosis of acute right lower limb ischemia was expected. He was admitted and underwent peripheral angiogram, showing occlusion of both common femoral arteries. This was intervened via access obtained from right brachial artery. Both occlusions were crossed with a V18 wire supported by Trailblazer. After serial dilatations with 3.0 mm, 4.0 mm and 6.0 mm balloons - both arteries were recanalized. Function of both legs were restored and he was able to ambulate with walking frame upon discharge.
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PTA 2.avi

Peripheral complications is an uncommon complications post TAVR. This is rarer in a subacute setting. Implanters need to be aware of such. Despite advances of using smaller sheaths for newer devices, one may not escape such catastrophe. Patient should be well educated on changes of lower limb function and should be advised to seek immediate medical attention is such changes occur. Prompt intervention will allow salvage function of occluded limbs. Alternatively, if assessment of femoral vascular complications' risk is too high then an alternate access route should be considered.