Use of Double Stiff Wire Allows Successful Transfemoral Transcatheter Aortic Valve Implantation Through Extreme Thoracic Aorta Tortuosity

An 80-year-old man affected by symptomatic (New York Heart Association III) aortic stenosis was referred to our center. Transthoracic echocardiogram showed low-flow low-gradient aortic stenosis (mean gradient 30 mm Hg, valve area 0.6 cm2, ejection fraction 35%). His past medical history included liver cirrhosis in chronic hepatitis C infection (Child-Pugh A6) and severe osteoporosis with chest deformation and restrictive pulmonary disease. His EuroSCORE was 15.4% and Society of Thoracic Surgeons score was 4.8%. Preoperative computed tomography revealed significant tortuosity of the descending thoracic aorta, with a double curve (Figure 1A–1C; Movie I in the Data Supplement) and a narrowest lumen diameter of 18 mm. Significant kinking was also present at the level of the right femoro-iliac axis (Figure 1B) with a minimum diameter was 9.1 mm at both sides. His aortic annulus size was calculated at 25×27 mm (area 540 mm2). After Heart Team discussion, in view of his multiple comorbidites, he was submitted to transcathter aortic valve implantation. Transfemoral route was deemed the most suitable access route because of the presence of restrictive pulmonary disease and increased associated risk with …