Ruptured Abdominal Aortic Aneurysm After Successful Transcatheter Aortic Valve Replacement- A Case Report and Review of Management

Michael S Trostler

doi:10.54289/jaad2100102

Abstract

Background: Transcatheter aortic valve replacement is an important procedure with the aging US population presenting with more aortic stenosis and as many as 10 % of these patients presenting with an abdominal aortic aneurysm at the time of screening. This procedure has also been shown to be as safe as open aortic valve replacement with lower risks of death, stroke, and rehospitalization. Case Report: A 91-year-old female presents approximately one month after transcatheter aortic valve with an acute retroperitoneal rupture of a known abdominal aortic aneurysm. The patient was taken for an emergent endovascular aortic aneurysm repair and became suddenly unresponsive and apneic prior to any anesthetic drug administration, the patient was intubated, and rapid transfusion was started. The procedure was completed successfully with immediate improvement in the patient’s vitals after deployment of the stent. The patient was recovering well, but five days later had a sudden pulseless electrical activity arrest and after appropriate but unsuccessful advanced cardiac life support was declared deceased. Conclusion: While not standard of care, a simultaneous endovascular aneurysm repair during transcatheter aortic valve repair in select patients seems to be a safe procedure without increase in complications from either procedure completed separately. The aim of this manuscript is to review the recent success of simultaneous repair and to illustrate that this newer method may improve outcomes.

Highlights

Transcatheter aortic valve replacement is an important procedure with the aging US population presenting with more aortic stenosis and as many as 10 % of these patients presenting with an abdominal aortic aneurysm at the time of screening
While abdominal aortic aneurysm (AAA) is often asymptomatic, ruptured AAA carries a significant risk of mortality, two-thirds die before arriving at the hospital, and only 42 % of those who receive treatment survive
The patient was discharged on apixaban for anticoagulation therapy after Transcatheter aortic valve replacement (TAVR), which may contribute to increased bleeding in the event of rupture, but with a new valve and her history of atrial fibrillation with left bundle branch block the risk of clot must be weighed against the risk of potential aortic aneurysm rupture

Summary

Background

Transcatheter aortic valve replacement (TAVR) has become the standard of care for patients with severe aortic stenosis (AS) at intermediate or high risk for surgical intervention and has recently been shown to have a lower risk of death, stroke, and rehospitalization compared to open surgery in low-risk patients.[1]. History was significant for severe AS status post TAVR one-month prior, moderate mitral regurgitation, coronary artery disease, diastolic heart failure, atrial fibrillation with left bundle branch block and tachy-brady syndrome status post pacemaker, and a known AAA She was found to have a rAAA and was transferred to the university hospital. Her aortic stenosis was severe prior to TAVR with a valve area of 0.8 cm and a mean gradient of 34 mmHg and was repaired with an Evolut Pro Plus 26 mm valve through a right common femoral cutdown Her medical problems were stable and well managed, and she was able to perform all activities of daily living (ADLs) without assistance and had returned to a NYHA Class I status.

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