TransCaval TAVI
Transcaval Transcatheter Aortic Valve Implantation (TAVI): A Step-by-Step Procedural Manuscript
1. Introduction
Transcaval access provides a viable alternative to transfemoral arterial access in patients with challenging iliofemoral anatomy. It involves creating a controlled fistulous connection between the inferior vena cava (IVC) and the adjacent abdominal aorta to permit delivery of the TAVI system. This manuscript outlines the detailed procedural steps for performing transcaval TAVI from puncture to closure.
2. Pre-Procedural Planning
2.1 CT Imaging Assessment
Multidetector CT angiography is critical.
Identify a suitable crossing site between the IVC and abdominal aorta:
Typically at the L3–L4 vertebral level.
Ensure minimal calcium and <12 mm separation.
No interposing bowel or spinal osteophytes.
2.2 Team Preparation
Multidisciplinary team involvement: interventional cardiology, vascular surgery, imaging, and anesthesia.
Informed consent including explanation of off-label transcaval access.
3. Procedural Equipment
Access Equipment:
6–7 Fr venous sheath (femoral vein)
5–6 Fr arterial sheath (contralateral femoral artery)
Crossing System:
0.014” stiff wire (Astato XS 20 or Confianza Pro 12)
Insulated microcatheter (e.g., Piggyback or NaviCross)
Electrosurgical generator (cut mode 50–70 W)
20 mm Gooseneck snare in aorta
Closure System:
8–12 mm Amplatzer Duct Occluder II or Muscular VSD occluder
TAVI Delivery System:
Based on valve type (e.g., Navitor, Evolut, Sapien)
14–20 Fr expandable sheath
4. Procedural Steps
4.1 Vascular Access
Right femoral vein puncture under ultrasound guidance.
Left femoral artery puncture for hemodynamic monitoring and aortic angiography.
Insert temporary pacing lead via femoral or jugular vein.
4.2 Targeting the Crossing Site
Place a pigtail catheter in the abdominal aorta (via femoral artery).
Insert a 6 Fr JR4 or MP catheter with a snare in the IVC (via femoral vein).
Use biplane fluoroscopy to align both catheters at the predetermined crossing site.
4.3 Caval–Aortic Crossing
Positioning:
Insert the insulated 0.014” wire inside a microcatheter in IVC.
Connect wire to electrosurgical pencil.
Crossing:
Activate electrocautery and advance wire through IVC wall into the aorta.
Wire is then captured by the aortic snare.
Wire Externalization:
Snare and externalize wire via femoral arterial sheath to establish an arteriovenous rail.
4.4 Tract Preparation
Dilate tract using sequential dilators or pre-shaped dilator sheaths.
Exchange for large-bore delivery sheath (e.g., 18–20 Fr).
Confirm stable hemodynamics and absence of retroperitoneal hemorrhage.
4.5 Valve Implantation
Proceed with standard TAVI procedure:
Position valve across aortic annulus.
Deploy under rapid pacing.
Confirm positioning and valve function with aortography and hemodynamic measurements.
4.6 Tract Closure
Remove TAVI Delivery System, leaving venous access in place.
Advance occluder device (e.g., Amplatzer Duct Occluder II) through venous sheath.
Deploy:
Position the distal disc in the aortic lumen.
Deploy the central waist and proximal disc within the IVC.
Avoid protrusion into the aortic lumen.
Confirm Hemostasis:
Perform aortography to assess closure.
Minor residual shunting is acceptable and often self-limiting.
5. Post-Procedural Care
Hemodynamic monitoring in ICU/CCU.
Hemoglobin and renal function surveillance.
Imaging (e.g., CTA within 24–72 hrs) to confirm occluder position and tract sealing.
Antithrombotic therapy per institutional protocol (typically DAPT for 3–6 months).
6. Potential Complications
Retroperitoneal hemorrhage
Occluder device migration or malposition
Aorto-caval fistula persistence
Hemolysis
Bowel injury or sepsis (rare)
7. Conclusion
Transcaval access enables TAVI in patients otherwise deemed inoperable due to vascular limitations. With proper imaging, careful technique, and adequate closure strategies, the procedure is safe and effective. Future advancements in dedicated transcaval closure devices and procedural planning software will likely enhance procedural safety and efficiency.
8. References
Greenbaum AB et al. Transcaval Access for TAVI in Patients with No Good Options: J Am Coll Cardiol. 2015.
Lederman RJ et al. Transcaval TAVR: Procedural Tips and Tricks. Catheter Cardiovasc Interv. 2019.
Rogers T et al. Contemporary Outcomes of Transcaval Access for TAVI: JACC Cardiovasc Interv. 2021.
TransCaval Approach TAVI
7F JR4 Guidecatheter 100cm
7F IM 55cm or JR4 55cm
Astato 20g 300cm angioplasty wire
Piggyback wire convertor (Vascular Solutions) or Navicross microcatheter 90cm (Terumo)
6F Finecross 130cm
Gooseneck snare (EV3) 25mm
Hemostasis valve for the Snare system
Lunderquist extra stiff wire
Diathermy pen and machine (Bovie system)
Closure:
BMW 300cm angioplasty wire (as buddy wire)
Amplatzer duct occluder 10/8 or 8/6 (1st generation)
6F Torqvue 180deg/80cm Delivery System (for duct occluder)
Agilis NxT small curl 8.5F 61cm
Bail out kits:
PTS-X 25mm sizing balloon (for balloon tamponade)
8F femoral sheath upgrade for sizing balloon
Endologix endografts and delivery system or
Trivascular ovation ix iliac limb extensions
Usual TAVI equipment
4F, 6F, 7F, 8F, 10F femoral sheaths
PROCEDURE Access:
ARTERIAL -> 6F
VENOUS -> 4F then upsize to 10F
Crossing System:
Astato 20g 300cm angioplasty wire (straight tip), inside a...
Piggyback wire convertor or 130cm Finecross, inside a...
Navicross braided 0.035 microcatheter, to deliver later...
Lunderquist wire
Attach the denuded end of Astato wire to diathermy pen with 50 pure CUT ONLY
Venous:
7F JR4 or IM 55cm guidecath to femoral vein
Arterial:
6F JR4 100cm guidecath with Gooseneck 25mm snare
Steps:
Simutaneously (with someone pressing the diathermy pen) advance the astato wire towards aorta side, then catch the wire with the snare in the aorta side then advance the whole system upwards.
Remove the astato wire and finecross and replace with Lunderquist wire
Then the usual TAVI routine.
Closure of Hole:
Amplatzer duct occluder system in the Agilis small curl system to position the 8/6mm plug, with Pigtail catheter in the arterial side to visualize position using Biplane views.
