Transcaval TAVR

[OB1🤙]

Just when you think you've seen it all, they spring this kind of stuff on you.

It intuitively seems like the dumbest thing you could possibly do to a person, but it turns out to be pretty damn slick. In the n=1 that I now have, anyway.

Anyone else doing these yet?

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[OB1🤙]

 

[OB1🤙]

You'd think that the patient would pretty much just die immediately if you made giant holes in both aorta and IVC. But it turns out if the retroperitoneum is unviolated (UNLIKE in penetrating trauma), the blood just shunts back into the IVC and back into the circulation. The hemodynamics stay rock solid. It's pretty frigging amazing.

Yay, physiology!

 

[Planktonmd]

What's the advantage?

 

[T-burglar]

bypassing diseased femoro-iliac system.

Currently the most common alternative access when these groin vessels are no good is either transapical or transaortic. Spearing the long axis of the ascending aorta, or the cardiac apex with the introducer requires a thoracotomy (a surgeon). Alternative access to the descending thoracic or abdominal aorta that doesn't require a surgical incision cuts out the surgeon

 

[sethco]

Is this communication done infrarenally? My concern would be compromised blood flow distal to the created Fistula in patients with already bad PVD (I.e. The ones that would benefit most from this procedure)

BTW, Trans-carotid? Don't think I have ever heard of that approach

 

[ThePlockIsHot]

We have done about 5, they are pretty impressive procedures. We've done them all under GA which we almost never do for our TF TAVRs, mainly because they take about twice as long, and as you mentioned, the anatomy of the procedure freaks me out a bit. No issues yet though that have had to put a balloon up in the aorta to close small fistula post-procedure about half the time. It's only up for 3 minutes at a time so there isn't much of a BP drop when they put it down. The only other pearl is to expect a transient 10-20mmHg MAP drop when they cross back to the venous side after the valve is deployed. It's tempting to treat, but this is a very bad time for a BP spike so I try to avoid it unless SBP is less than 80. It usually comes back on its own after about 60 seconds.

 

[AdmiralChz]

Hospital cross town did a few of these in the trial stage (maybe still in trials?) which apparently resulted in a couple fatalities from retroperitoneal bleeds. So people around here are very wary of this technique (it's a huge introducer for some of these valve deployment devices going across the vessels), for now.

 

[T-burglar]

I think sometimes people lose sight of the fact that an AVR is the most straightforward cardiac operation, and also that a small thoracotomy is not the worst thing in the world.. I would have a hard time deciding to take the risk of a new procedure like this over a traditional AVR (depending on why I am "inoperable") or a transapical TAVR.

 

[OB1🤙]

Suffice it to say this was an inoperable patient.

 

[McPoyle]

No, but one of my last days as a resident we did a tavr for this lady with congenital short stature and a bunch of contractures. Ended up with a laparotomy by vascular who then placed an aortic conduit for cardiology to perform the procedure through. Pretty wild.