Importance of Instant Thrombectomy to Treat Cerebral Vessel Occlusion During TAVI in Third World Country

Abstract

Background: Transcatheter aortic valve implantation (TAVI) is considered to be one of the treatments for symptomatic severe aortic stenosis. This procedure has been associated with cerebrovascular events be it thromboembolic or hemorrhagic in nature that increase the periprocedural mortality and morbidity. Strokes post TAVI are mostly ischemic in origin; they can be either due to symptomatic or silent emboli. These thromboembolic events may occur during the procedure or up to 2 months after the procedure. In the acute setting, especially during the procedure, immediate intervention is crucial for better patient outcome. Mechanical thrombectomy is the best treatment modality for immediate revascularization and stroke prevention. Case description: We present a case of a patient who developed symptomatic signs of hypoperfusion during the procedure that required an urgent mechanical thrombectomy in a third world country. The patient didn’t undergo CT imaging and wasn’t transferred to the brain angiography suite; the procedure was done using the x-ray machine and in the cardiology catherization lab which lacks proper equipment to do cerebral DSA (Digital subtraction angiography). This case is the 8th to be reported in the literature where mechanical thrombectomy was done on the table during a TAVI procedure. Based on this case and the literature review, we will propose an algorithm for dealing with similar cases. Conclusion: We highlight the importance of instant thrombectomy that should be done in a patient suffering from a thromboembolic event while performing TAVI procedure. Using the same endovascular access, in the same setting in the cardiac catherization lab to assess thrombus location, even if done sub-optimally without DSA, in correlation with patient’s symptoms, without taking the patient to perform a CT scan, is life saving and guarantees quick reperfusion after clot aspiration with clinical improvement afterwards and better patient outcome.