First application of the distal radial approach for severe mechanical surgical aortic valve paravalvular leak transcatheter closure with double vascular plug: a case report

Severe aortic paravalvular leaks (PVL) after surgical mechanical aortic valve replacement (AVR) represent high risk for congestive heart failure, haemolysis and infective endocarditis. This is the first case of distal radial artery (DRA) access use for severe mechanical aortic paravalvular leak closure with sequential double vascular plug guided by computed tomography angiography (CTA), transoesophageal echocardiography (TOE) and 3D TOE in acute setting. A 51-year old male presented with significant mixed aortic valve disease. According to guidelines AVR was performed (Slimline Bicarbon A-25mm). Four and 16 days later re-exploration was carried out due to pericardial effusion. Four months after discharge from rehabilitation the patient was readmitted due to worsening dyspnoea on exertion, then at rest. Transthoracic echocardiography (TTE), TOE and consequently CTA revealed severe PVL. Transcatheter PVL closure was opted. DRA access was preferred. After CTA scan analysis, angiographic, TOE and 3D TOE visualization of the leak a 14/5mm and a 10/5mm vascular plug (AVPIII) was deployed to achieve good result. 9-month clinical, echocardiographic and CTA follow up revealed good long term result. For transcatheter PVL closure CTA is helpful with not only vascular access planning, but visualization of the leak size, location and device planning. This case demonstrates that the distal radial approach is feasible in cases of severe mechanical aortic valve PVL retrograde transcatheter closure. DRA access could possibly represent less bleeding and vascular access site complications when compared with femoral access and has some potential advantages over regular radial access.