title: Fatal ischemic stroke related to nonpermissive peripheral artery access for percutaneous aortic valve replacement.
abstract: This report describes an 85 year-old man who underwent percutaneous aortic valve replacement (PAVR). With a logistic euroSCORE of 37%, the patient had been refused surgical aortic valve replacement because of an unacceptably high peri-operative risk. During the PAVR procedure, severe resistance was encountered when advancing the 21 Fr delivery catheter through the left iliac artery despite pre-dilatation with a 7 mm balloon. Following this, PAVR was promptly achieved without difficulty, with excellent valve positioning, no peri-valvular leak and good hemodynamics. However, transesophageal echocardiography revealed a mobile echogenic mass within the outflow tract of the left ventricle. The mass was retrieved with a cardiac bioptome manipulated via the left femoral artery through a 9 Fr sheath. A right cerebral ischemic stroke manifested shortly after the post-procedure and the patient died on the fourth post-operative day. Post-mortem findings revealed a left subclavian artery occlusion by iliac vascular tissue. This report highlights the imperative for device-specific vascular access screening criteria and the need to minimize device size in order to safely accomplish PAVR.
authors.affiliation: Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada.
authors.forename: Colin
authors.initials: C
authors.lastname: Berry
authors.forename: Raymond
authors.initials: R
authors.lastname: Cartier
authors.forename: Raoul
authors.initials: R
authors.lastname: Bonan
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000628:therapy*; D001705:Bioprosthesis / Q000009:adverse effects*; D002404:Catheterization / Q000009:adverse effects*; D017548:Echocardiography, Transesophageal; D017809:Fatal Outcome; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D007083:Iliac Artery / Q000293:injuries*; D008297:Male; D020521:Stroke / Q000209:etiology*; D013348:Subclavian Artery; D014655:Vascular Resistance