Transcatheter Aortic Valve Replacement in a Patient With Right-Side Dominant Double Aortic Arch.

BACKGROUND

Double aortic arch (DAA) is a rare congenital vascular anomaly that is typically diagnosed in infancy. In adult patients undergoing transcatheter aortic valve replacement (TAVR), an undetected DAA can present unique anatomical and procedural challenges.

CASE SUMMARY: A 71-year-old woman with end-stage renal disease and severe aortic stenosis was incidentally found to have a DAA during preprocedural TAVR evaluation. The device was inserted via the right femoral artery, as it provided the largest vessel diameter and most favorable anatomy for device passage. The pronounced curvature of the aortic arch created an unfavorable anatomy that hindered advancement of the delivery system, even with multiple attempts using a double-stiff wire technique. Ultimately, a snare-assisted approach enabled successful navigation and valve deployment. The patient later developed postprocedural stroke, and the use of cerebral embolic protection was limited by her complex arch anatomy.

DISCUSSION: This case highlights the critical role of comprehensive imaging and individualized procedural planning in managing rare vascular anomalies during TAVR. It provides practical insight into overcoming severe arch tortuosity with snare-assisted techniques, offering educational value for interventionalists encountering similar structural challenges.

TAKE-HOME MESSAGE: Snare-assisted techniques offer a practical solution for TAVR in patients with complex arch anatomy when standard approaches fail.