Acute Leaflet Opening Restriction Caused by Endarterectomy-like Iliac Artery Intimal Detachment Entrapped within a Self-expanding Transcatheter Aortic Valve: a Case Report

Structured Abstract Background Acute transcatheter heart valve (THV) dysfunction immediately after transcatheter aortic valve implantation (TAVI) is uncommon but can be catastrophic. Mechanical obstruction by migrated vascular tissue is exceptionally rare. Case summary An 80-year-old woman with symptomatic very severe aortic stenosis and high surgical risk underwent transfemoral TAVI with a 23-mm self-expanding Evolut FX valve (Medtronic, Minneapolis, MN, USA). Preprocedural computed tomography (CT) showed severe circumferential calcification of the left common iliac artery (CIA) with a preserved lumen (6.8 × 4.9 mm) and a small aortic annulus (area, 244.9 mm²; perimeter, 55.9 mm). After valve deployment, invasive haemodynamics showed no reduction in the transvalvular pressure gradient (mean/peak, 58/97 mmHg before vs. 63/98 mmHg after deployment). Transoesophageal echocardiography (TEE) demonstrated a tubular structure restricting leaflet opening. Balloon post-dilatation resulted in transient echocardiographic improvement but was complicated by balloon rupture, and a mobile intravalvular structure persisted. Emergency surgical conversion was performed. Intraoperatively, a calcified tubular structure with a lumen-like appearance was found on the guidewire and was impinging on the THV leaflets. The THV was explanted, and surgical aortic valve replacement was performed. Histology confirmed calcified vascular intimal tissue, consistent with detachment from the left CIA. The postoperative course was uneventful, and the patient was discharged home. Discussion In severely calcified iliofemoral access, endarterectomy-like intimal detachment can occur during device passage and, rarely, can migrate into a self-expanding THV, causing acute leaflet opening restriction. Early recognition using multimodality imaging and timely surgical bailout may be life-saving.