# Transfemoral transcatheter aortic valve-in-valve implantation using endoconduit in a patient with right-sided aortic arch and complex vascular anatomy: a case report

## TL;DR

A patient with a complex vascular anatomy successfully underwent a transfemoral valve-in-valve TAVI procedure using an endoconduit technique.

## Contribution

Demonstrates successful use of endoconduit for transfemoral TAV-in-TAV in a patient with a right-sided aortic arch and complex vascular anatomy.

## Key findings

- Emergency transfemoral TAV-in-TAV was successfully performed using a 23 mm SAPIEN3 Ultra RESILIA valve.
- Endoconduit technique facilitated sheath passage and resulted in minimal paravalvular regurgitation.
- Post-operative Doppler Velocity Index suggested no significant patient–prosthesis mismatch.

## Abstract

The number of transcatheter aortic valve implantation (TAVI) procedures has increased significantly and now includes younger and higher-risk surgical patients. As early-generation transcatheter heart valves (THVs) continue to degrade over time, the incidence of structural valve deterioration (SVD) is increasing, requiring more complex valve-in-valve (TAV-in-TAV) procedures.

We present a case of SVD of a THV, resulting in severe aortic regurgitation in an 88-year-old female with decompensated heart failure. Eight years prior, the patient had undergone TAVI with SAPIEN XT 23 mm via the transapical approach because of severe calcified stenosis of the lower extremity arteries and extreme tortuosity from the arch to the descending aorta and abdominal aortic aneurysm, right-sided aortic arch. Considering the patient’s condition and access route, we performed emergency transfemoral TAV-in-TAV using a 23 mm SAPIEN3 Ultra RESILIA. The endoconduit technique successfully facilitated sheath passage. The valve was implanted without complications. The procedure was successful, resulting in only trace paravalvular regurgitation. The post-operative effective orifice area was 1.80 cm² (indexed EOA: 1.32 cm²/m²). The Doppler Velocity Index was 0.59, suggesting no significant patient–prosthesis mismatch.

Vascular anomalies often restrict the choice of a safe access route in TAVI procedures. The endoconduit technique provides a minimally invasive solution for accessing complex iliac arteries. This case illustrates the importance of selecting the appropriate sheath, utilising endoconduit, and employing various procedural techniques to manage complex anatomies and ensure successful outcomes in TAV-in-TAV procedures.