Transcatheter aortic valve replacement (TAVR) is an alternative to aortic valve replacement via sternotomy for high- and intermediate-risk patients.1,2 Despite the improving safety of the TAVR procedure,3 vascular injury remains a significant complication. Compression of the tracheobronchial tree due to vascular anomalies or aneurysms has been previously described,4–7 although none in the setting of TAVR. We report a case of tracheal compression causing respiratory compromise due to a vascular injury during a TAVR via the right subclavian artery approach. Written Health Insurance Portability and Accountability Act authorization was obtained from the patient’s health care representative before submission of this case report.
An 82-year-old woman who was 4′8′′ tall, weighed 121 lbs, and had a history of peripheral artery disease requiring lower extremity endovascular stenting, chronic obstructive pulmonary disease, and coronary artery disease with a stent to the left circumflex artery presented for an elective TAVR procedure. Transthoracic echocardiography revealed a preserved left ventricular ejection fraction, moderate-to-severe tricuspid regurgitation, mild-to-moderate mitral regurgitation, and severe aortic stenosis.
A computed tomography angiogram of the chest, abdomen, and pelvis was obtained for vascular planning before her scheduled procedure (Figure 1). This was notable for severe atherosclerotic disease in the bilateral common iliac arteries with complete occlusion of the proximal right common iliac artery and near-complete occlusion of the left common iliac. There was stenosis of both subclavian arteries, but this was more severe on the left. After consideration of these findings, right subclavian artery access was deemed to be the best approach for the procedure.
After left radial arterial line insertion, general endotracheal anesthesia was initiated and large-bore peripheral venous access was obtained. The right subclavian artery was identified by surgical cut down, and a 5-French sheath was introduced. A 14-French dilator was used to dilate the subclavian artery to allow for advancement of a 29-mm CoreValve Evolut (Medtronic Inc, Minneapolis, MN) prosthesis. The valve was advanced through the subclavian artery and across the aortic valve where it was deployed. Aortography revealed moderate paravalvular regurgitation, and postdilation of the prosthesis was planned. The CoreValve delivery system was withdrawn from the right subclavian artery and a 14-French sheath and balloon catheter were advanced, but resistance was encountered. Subsequent aortography revealed a right subclavian artery dissection and extravasation of contrast around the subclavian artery and aortic arch (Figure 2). At this time, the patient’s mean arterial blood pressure acutely decreased from 104 to 36 mm Hg. Multiple boluses of norepinephrine and vasopressin were administered, and a norepinephrine infusion was started to normalize the patient’s blood pressure.
Concurrently, peak inspiratory pressures acutely increased from 15 to 35 mm Hg with decreased tidal volumes (maximum volumes of 50–200 mL). Manual ventilation via a bag valve mask (BVM) was initiated and allowed delivery of larger tidal volumes to the patient and stabilization of her respiratory status, suggesting that the ventilation changes were procedure related. Although TAVRs in our institution are usually guided by fluoroscopy and transthoracic echocardiography, a transesophageal echocardiography probe was emergently placed which revealed a hematoma surrounding the distal aortic arch and descending thoracic aorta without evidence of an aortic dissection. Fiberoptic bronchoscopy showed the posterior membranous trachea bulging forward from the level of the midtrachea extending down to the carina, consistent with external compression from the periaortic hematoma. This compression caused a decrease of approximately 75% in the area of the trachea.
After recognition of this vascular injury, 2 subclavian artery stents were deployed which stopped further bleeding. Ventilation via BVM was continued due to high inspiratory pressures. Because of continued difficulty in ventilating the patient, an incision was made along the right sternocleidomastoid muscle and dissected inferiorly down to the mediastinal space. Evacuation of the mediastinal hematoma markedly improved ventilation, normalizing peak inspiratory pressures and allowing the patient to be placed back on the mechanical ventilator. The patient was subsequently transported to the cardiothoracic intensive care unit intubated and sedated.
The patient was extubated on postoperative day 1, transferred out of the intensive care unit on postoperative day 4, and ultimately discharged to home in good condition on postoperative day 7. Postoperative transthoracic echocardiogram 1 month later demonstrated a well-positioned aortic valve prosthetic with normal gradients and only trace paravalvular leak.
Compared to their first-generation counterparts, newer TAVR devices use smaller sheaths, allow for valve repositioning and/or retrieval, and are suitable for alternative vascular access points.8 The common femoral artery remains the preferred vascular access site, used in more than half of all TAVR procedures.9 The transapical approach was the earliest alternative to transfemoral access. It is still used today, primarily in patients with advanced atherosclerotic disease involving the aortoiliac system, aortic arch, and ascending aorta. However, this approach requires thoracotomy and is substantially more invasive than a transfemoral approach.10 The subclavian artery approach was developed to avoid the transapical approach for patients with undesirable aortoiliac anatomy. Overall, this approach has demonstrated a comparable safety profile to the transfemoral approach.11 While either subclavian artery is a potential site of access for TAVR, the right subclavian artery is not preferred because of the more acute angle between the brachiocephalic artery and the ascending aorta that the delivery system must traverse as compared to a left-sided approach. Comprehensive preprocedural vascular imaging is important for determining the most appropriate arterial access site and avoiding vascular injuries. The right subclavian artery was used for access in this patient because of her extensive iliac atherosclerotic disease and stenosis in her left subclavian artery. This access site, combined with the patient’s small size, combined to increase her risk for iatrogenic vascular injury.
Major vascular injuries are an important complication of the TAVR procedure and are associated with increased mortality.12 However, because TAVR technology has improved and delivery systems have become smaller, these complications have become rarer. Major vascular complications have decreased from 11.9% with the larger, first-generation systems to 4.5% with the smaller, second-generation systems. All-cause mortality has also decreased from 7.8% with first-generation systems to 4.1% with second-generation systems.13 The system used for this patient, the CoreValve Evolut, was a second-generation system.
Airway compression due to thoracic aortic aneurysms has previously been reported.4–7 Like in those cases, this patient experienced compression of the trachea from the posterior side due to a vascular pathology. However, the etiology in this case was not due to an aneurysm of the thoracic aorta, but rather due to the mass effect caused by the periaortic hematoma formed after the injury to the right subclavian artery. To our knowledge, this is the first description of tracheal compression resulting from a vascular complication during TAVR.
Currently, our institution uses general anesthesia with endotracheal intubation in patients undergoing TAVR via the subclavian artery approach. The presence of an endotracheal tube at the time of arterial injury made ongoing ventilation possible with a BVM even before a definitive diagnosis of tracheal compression had been made. Alternatively, the fiberoptic bronchoscope could have been used to achieve single-lung ventilation by advancing the endotracheal tube past the level of the compression and into a mainstem bronchus. However, TAVR is increasingly being performed in nonintubated patients under sedation. A vascular complication such as this would be poorly tolerated by a spontaneously breathing patient. There could be delayed recognition of the complication and increased difficulty in treatment, possibly resulting in a poor outcome. These reasons further support our practice of electively intubating all patients undergoing TAVR via the subclavian artery approach. Some centers electively institute extracorporeal membrane oxygenation (ECMO) in very high-risk patients undergoing TAVR, such as those with severely impaired left ventricular function or severe pulmonary hypertension.14,15 However, ECMO use could also be considered as a rescue modality in patients such as this. In these instances, venovenous ECMO could temporize the patient’s respiratory status until definitive management could take place.
Given that patients undergoing TAVR frequently have serious comorbidities, anticipation and early treatment of complications are imperative. While any intravascular device introduced via the right subclavian artery might cause a similar injury, the relatively large size and rigidity of TAVR delivery systems make them especially high risk. This case highlights the importance of considering a major vascular injury causing airway compression as a potential complication of TAVR.
Name: Diana S. DeAndrade, MD.
Contribution: This author helped acquire the data, review the literature, and draft and revise the manuscript.
Name: Nicholas F. Smith, BS.
Contribution: This author helped acquire the data, review the literature, and draft and revise the manuscript.
Name: Stephen M. McHugh, MD.
Contribution: This author helped acquire the data, review the literature, draft and revise the manuscript, and with clinical management.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
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