Transcarotid-transcatheter aortic valve implantation in a patient with low cardiac function and haemodialysis accompanied by intracranial carotid stenosis: a case report.

Background: In transcatheter aortic valve implantation, the transfemoral approach is commonly used, but challenging access and procedural difficulties are sometimes encountered. Among alternatives, the transcarotid approach is increasingly used. We present a case of transcatheter aortic valve implantation in which a left common carotid approach achieved favourable outcomes in a patient with low cardiac function and dialysis. Case summary: The patient was a 67-year-old woman with a history of coronary artery bypass surgery and dialysis. Heart failure secondary to aortic stenosis and hypotension during dialysis required surgery. Echocardiography indicated severe aortic stenosis with low-flow low-gradient. Access was problematic, with 4.0 mm diameter calcified external iliac arteries. Severe calcific stenosis was observed in the left subclavian artery, and the presence of right internal thoracic artery bypass rendered the bilateral subclavian artery approach unsuitable. Given the history of open-heart surgery and reduced left ventricular function, the carotid approach was chosen; however, both internal carotid arteries showed moderate stenosis. Carotid compression magnetic resonance angiography confirmed intracranial communication, so we chose access through the more severely stenosed left common carotid artery. Under preoperative extracorporeal membrane oxygenation and general anaesthesia, transcatheter aortic valve implantation was performed with a Sapien3 Ultra RESILIA 23 mm valve. Postoperatively, there was no symptomatic cerebral infarction, and the dialysis-related hypotension resolved. Discussion: Even with intracranial carotid stenosis, flow evaluations, such as Matas test magnetic resonance imaging assessments, can reduce the cerebral infarction risk during transcarotid-transcatheter aortic valve implantation, providing a potentially safe and minimally invasive alternative access.