Intravascular Lithotripsy-Assisted Transfemoral TAVI: The Copenhagen Experience and Literature Review

Fadi J Sawaya, Vilhelmas Bajoras, Maarten Vanhaverbeke, Christina Wang, Gintautas Bieliauskas, Lars Søndergaard, Ole De Backer, Fadi J Sawaya, Vilhelmas Bajoras, Maarten Vanhaverbeke, Christina Wang, Gintautas Bieliauskas, Lars Søndergaard, Ole De Backer

Abstract

Transcatheter aortic valve implantation (TAVI) is currently an established therapy for elderly patients with symptomatic severe aortic valve stenosis across all surgical risk categories. Access is an important aspect when planning for and performing TAVI. The superiority of a transfemoral (TF) approach compared to a transthoracic (transapical, direct aortic) approach has been demonstrated in several studies. Recently, the introduction of intravascular lithotripsy (IVL) has made it possible to treat patients with calcified iliofemoral disease by TF approach. This article aimed to provide a comprehensive overview on the following aspects: (1) preprocedural planning for IVL-assisted TF-TAVI; (2) procedural aspects in IVL-assisted TF-TAVI; (3) outcomes of IVL-assisted TF-TAVI in an experienced TAVI center; and (4) literature review and discussion of this new emerging approach.

Keywords: access; calcified; lithotripsy; transcatheter aortic valve implantation (TAVI); transfemoral (TF).

Conflict of interest statement

OD received speaker fees from Shockwave Medical Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Sawaya, Bajoras, Vanhaverbeke, Wang, Bieliauskas, Søndergaard and De Backer.

Figures

Figure 1
Figure 1
Fully percutaneous TAVI program. A fully percutaneous TAVI program is safe and feasible using different access routes: routine transfemoral, IVL-assisted transfemoral, percutaneous transaxillary and transcaval approaches. IVL, intravascular lithotripsy; TAVI, transcatheter aortic valve implantation.
Figure 2
Figure 2
Preprocedural CT analysis. Preprocedural computed tomography (CT) angiography analysis of the iliofemoral access. Standard assessments include: (A) Maximal and minimal diameter measured at the minimal luminal diameter (MLD) of the vessel. (B,C) Circumference of calcification: 360° or horseshoe-like (270°) calcification. (D) Total length of the vessel calcification(s). Copenhagen recommendations on feasibility of IVL-assisted TF-TAVI based on CT angiography analysis. IVL, intravascular lithotripsy; TAVI, transcatheter aortic valve implantation; TF, transfemoral.
Figure 3
Figure 3
Shockwave IVL system components. The Shockwave IVL system consists of three components: (1) a portable IVL generator, (2) a connector cable with magnetic connection and push-button activation, and (3) an IVL catheter that houses an array of lithotripsy emitters enclosed in an integrated PTA balloon. IVL, intravascular lithotripsy; PTA, percutaneous transluminal angioplasty.
Figure 4
Figure 4
Step-by-step guide. (A) Treatment of a stenotic calcified common iliac artery with a 7 mm Shockwave IVL catheter. The use of a contralateral or ipsilateral 0.018” safety wire is strongly recommended. (B) Angiographic control with contrast injection is recommended after withdrawal of the large bore introducer sheath and vascular closure. IVL, intravascular lithotripsy; TAVI, transcatheter aortic valve implantation; TF, transfemoral.

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