Femoral-to-Carotid Shunting During Carotid-Access TAVR in Moyamoya-Pattern Vasculopathy.

BACKGROUND

Carotid access is an alternative for transcatheter aortic valve replacement (TAVR) in patients with prohibitive transfemoral anatomy, but it may cause cerebral hypoperfusion with impaired intracranial collateral circulation.

CASE SUMMARY: A 67-year-old woman with symptomatic severe aortic stenosis, extensive comorbidities, and unsuitable transfemoral access underwent TAVR. Neuroimaging demonstrated moyamoya-pattern intracranial vasculopathy with limited collateral reserve. During left carotid exposure, test occlusion caused a >50% decline in cerebral near-infrared spectroscopy despite blood pressure augmentation. A femoral-to-carotid arterial shunt was established to maintain cerebral perfusion. A 26-mm self-expanding Evolut FX+ valve was successfully implanted via left carotid access, with excellent hemodynamics and no neurologic complications.

DISCUSSION: This approach demonstrates a novel cerebral protection strategy for selected patients with compromised cerebrovascular reserve.

TAKE-HOME MESSAGES: Carotid-access TAVR in moyamoya-pattern vasculopathy carries hypoperfusion risk. Real-time near-infrared spectroscopy may detect intolerance to carotid clamping, while femoral-to-carotid shunting may offer cerebral protection.