Axillary Artery Occlusion after TAVR reported in NEJM

Dr Alexander Kille and Dr Willibald Hochholzer at University Heart Center Freiburg–Bad Krozingen, Bad Krozingen, Germany have reported a rare case of Axillary Artery Occlusion after TAVR. The case has appeared in the New England Journal of Medicine.

Transcatheter aortic valve replacement (TAVR) is a relatively newer therapeutic modality which offers a promising alternative to surgical aortic valve replacement for patients with prohibitive, high and intermediate surgical risk. Although there is a striking decrease in all-cause mortality and cardiovascular outcomes between TAVR and standard therapy at 5 years in high-risk patients, there is a significant component of associated major vascular complications such as annular rupture, vessel dissection, major bleeding. Safe access for implantation has remained a critical determinant of success, and not all patients are amenable to the femoral route. The transapical approach has proven to be another important option. Alternatively, the subclavian approach has recently been explored as another option and the CoreValve prosthesis has recently gained CE mark in the European market for this route Prevention, early identification and effective management of vascular access complications remain an important aspect of managing patients undergoing TAVR.

An 84-year-old man had a sudden onset of severe pain and weakness in the right arm 7 days after undergoing transcatheter aortic valve replacement (TAVR) for symptomatic aortic stenosis. Physical examination showed a pale right forearm, non-palpable right radial and brachial pulses, and reduced strength in the right arm.

Three-dimensional computed tomographic angiography revealed an occlusion of the right axillary artery (Panel A, arrow), and a two-dimensional angiogram showed hypo attenuated thickening of the noncoronary and left coronary aortic leaflets (Panel B, arrows). Surgical thrombectomy was performed, and a fresh thrombus was removed. Transesophageal echocardiography that was performed after thrombectomy revealed a thickened noncoronary aortic leaflet but no intracardiac thrombus. The transvalvular gradient was measured at 15 mm Hg, an increase from 8 mm Hg measured after TAVR. After thrombectomy, the pain and weakness in the patient’s right arm resolved. Aspirin and clopidogrel, which had been the dual antiplatelet therapy initiated after TAVR, were discontinued, and treatment with an oral anticoagulant was initiated.

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