DP25: TRANSCAROTID TAVR: AN ALTERNATIVE TO TRANSFEMORAL ACCESS IN PERIPHERAL VASCULAR DISEASE
Armando Exposito, Student; Jackeline Porto, MD; Jessica Alonso, MD; Omar Chahine, DO; Shayla McMahon, MD; Raul Bermudez, MD; Christopher Ochner
HCA Florida Kendall Hospital
Transcatheter aortic valve replacement (TAVR) is an established therapy for severe aortic stenosis in high-risk surgical patients. While the transfemoral approach is preferred, severe peripheral vascular disease (PVD) may preclude iliofemoral access, necessitating alternative routes such as transcarotid access. The transcarotid approach introduces unique anesthetic considerations, particularly regarding cerebral perfusion, hemodynamic management in fixed left ventricular outflow obstruction, and respiratory optimization in patients with limited pulmonary reserve. This abstract presents a case highlighting these perioperative anesthetic challenges.
A 78-year-old male with hypertension, type 2 diabetes mellitus, coronary artery disease status post coronary artery bypass grafting (CABG ×3), severe peripheral vascular disease, pulmonary fibrosis, and symptomatic severe aortic stenosis (aortic valve area 1.0 cm²) was scheduled for TAVR. Severe PVD rendered transfemoral access unsuitable, and a transcarotid approach was selected. Preoperative echocardiography demonstrated severe calcific aortic stenosis with preserved left ventricular systolic function. His pulmonary fibrosis and prior cardiac surgery further increased procedural risk.
Given the need for surgical carotid cutdown and the potential for abrupt hemodynamic changes during valve deployment, general anesthesia was chosen. A radial arterial line was placed pre-induction to allow continuous blood pressure monitoring. Cerebral oximetry was utilized to monitor regional cerebral oxygen saturation due to the risk of ipsilateral cerebral hypoperfusion during carotid artery clamping and large-bore sheath placement.
Induction of anesthesia was carefully titrated to avoid hypotension in the setting of severe aortic stenosis. Etomidate was selected to minimize myocardial depression, and vasopressors were immediately available to maintain coronary and cerebral perfusion. Hemodynamic goals included maintaining sinus rhythm, preserving preload, avoiding systemic hypotension, and sustaining adequate systemic vascular resistance. Maintenance anesthesia consisted of a balanced technique using low-dose volatile anesthetic and opioid supplementation to reduce myocardial oxygen demand while maintaining stability.
Ventilation was managed with lung-protective strategies due to underlying pulmonary fibrosis, utilizing low tidal volumes and cautious application of positive end-expiratory pressure to avoid impairing venous return. During carotid manipulation and sheath insertion, mean arterial pressure was maintained at or slightly above baseline to optimize cerebral perfusion pressure. Rapid ventricular pacing during valve deployment produced transient hypotension, which was promptly treated with vasopressor support and volume optimization.
The valve was successfully deployed without neurologic or major cardiovascular complications. The patient was extubated in the operating room following confirmation of adequate respiratory function and neurologic responsiveness and transferred to the intensive care unit for close postoperative monitoring.
This case underscores the anesthetic complexity of transcarotid TAVR in patients with severe peripheral vascular disease. In addition to the physiologic challenges of severe aortic stenosis, anesthesiologists must anticipate cerebral perfusion risks associated with carotid instrumentation and rapid pacing-induced instability. Meticulous hemodynamic control, cerebral monitoring, and coordinated multidisciplinary communication are essential to optimize outcomes in these high risk patients.