Enabling Transfemoral TAVI Through a Hostile Abdominal Aortic Anatomy and a Migrated Mesenteric Stent Fragment: Review of the Literature and a Case Presentation

Hostile abdominal aortic anatomy may limit transfemoral transcatheter aortic valve implantation (TAVI), even when the iliofemoral access vessels are suitable. The principal anatomical substrate is advanced atherosclerotic calcification, which may cause luminal stenosis, reduced arterial compliance, and an increased risk of vascular injury or embolization during large-bore device passage. Evidence regarding endovascular access facilitation is derived predominantly from iliofemoral interventions, whereas experience with direct modification of the abdominal aorta remains limited. This review examines balloon angioplasty, intravascular lithotripsy, and other endovascular strategies used to facilitate transfemoral TAVI in hostile iliofemoral and aortic anatomy, complemented by an illustrative case highlighting the additional challenge posed by intraluminal foreign material. Within this context, we present a 75-year-old high-risk patient with symptomatic severe aortic stenosis and significant coronary artery disease, in whom otherwise suitable iliofemoral access was complicated by focal calcific abdominal aortic stenosis and an asymptomatic impacted fragment of a fractured superior mesenteric artery stent following a previous intervention. A staged strategy comprising coronary revascularization, abdominal aortic balloon angioplasty with apposition of the fragment against the aortic wall, and subsequent balloon-expandable TAVI was successfully performed. This case underscores the importance of individualized, imaging-guided planning for complex transfemoral access.