CASE
An 83-year old male had symptomatic severe PAR New York Heart Association Functional Classification IV with a type III endoleak was recognized 4 years after TEVAR. A multislice spiral computed tomographic (MDCT) scan revealed a slightly dilation aortic root and ascending aorta without any calcification of the aortic valvular cusps. MDCT-scan showed an annulus perimeter of 86.6 mm and effective diameter of 27.6 mm. The examination also revealed excessive type III endoleak due to disconnection of proximal stent graft segments in the upper TAA(Figure 1A-C). The STS risk score revealed an excessive perioperative mortality risk of 19.1%. The complex anatomy, lack of calcification landmarks and the block of stainless steel stent-graft at the intraoperative fluoroscopy angiogram were the challenges during the TAVR procedure.
The patient was qualified for endovascular treatment of type III endoleak due to high risk of aneurysmal sac rupture. After initial angiography to determine the location of the endoleak. The low profile Valiant Thoracic Stent Graft was delivered with a tight guidewire. The inserted segment successfully sealed the rupture thoracic graft(Figure 2A-C and Movie S1). Transoesophageal echocardiogram (TEE) and angiography were used for evaluation of the valve movement and function (Figure 2 D and Figure 3A-C) . An incision of 3 cm in the corresponding costal space and then the apical puncture was done and a super-stiff guidewire was placed in position. A 29 mm J-Valve was directly inserted into the annulus with the aid of the specifically designed delivery system. The delivery system was bluntly inserted into the left ventricle through the apex and advanced into a supra-annular position under fluoroscopic guidance. While the stainless stent-graft effect on visual of operation, the three claspers were completely deployed and were pulled down to make sure the claspers being inside the aortic sinus. The implantation process was consisted of two steps, in the first step, the clasper was positioned into the aortic sinuses correctly. In the second step, the valve was lowed back gently into the annular plan with the guidance of the claspers embracing the native leaflets and deployed. A repeat aortic root angiography revealed no aortic insufficiency (AI) and no paravalvular leak (PVL).(Figure 2 E/E'-H/H' and Movie S2) . TEE was also used to confirm the valve function during the procedure and showed normal function of the J-Valve with a mean transaortic pressure gradient (PGmean) of 4 mm Hg and no aortic insufficiency or PVL (Figure 3D-F ). TTE discharge showed an aortic valve area of 2.6 cm2 with PGmean of 3 mm Hg and 4 mm Hg at 6 months, no AI. And there were no endoleaks detected during monitoring MDCT scan at 6 months follow-up (Figure 1D-F).