Evolut and future coronary access
The design of the Evolut frame, together with minor procedural adjustments and catheter selection based on the patient’s anatomy, helps facilitate post-TAVI coronary access. Highlights of this unique frame design include:
- Frame support — The frame reduces the need for additional backup catheters with more aggressive shapes.
- Narrow waist — This allows more space between the frame and the coronary ostia.
- Frame cell size — Cells are sized to accommodate all standard coronary access tools up to 10 Fr.
Tailoring the procedure
With a few essential considerations, you can access coronaries through the Evolut frame, optimize post-TAVI coronary access procedures, and approach these cases with confidence.
1. Perform aortogram
Insert pigtail within Evolut frame, choose an orthogonal view of desired coronary, and perform an aortogram.
2. Select catheter
Exchange to catheter shape based on root size/shape and location of commissure; downsize by 0.5 cm.
3. Approach coaxially
Approach coronary coaxially, remain perpendicular to frame. Do not approach from below.¹ Use J-wire for aid.
4. Engage and continue
Image courtesy of James Harvey, M.D.
Perform nonselective angio/use guidewire and guide extension devices to reach ostium and perform diagnostic/PCI.
5. Disengage safely
Image courtesy of Harold Dauerman, M.D.
Always disengage catheter/guide over a guidewire.
The considerations for post-TAVI coronary access were created through a detailed review of available data, including publications and proctor input. These methods (including the use of accessory devices) have not been verified through bench testing.
For more detailed information, get our interactive procedural guidance document for post-TAVI coronary access.
High success rate for unplanned PCI2
Unplanned post-TAVI PCI is a rare but serious situation. Fortunately, data from a 15,325-patient multicenter international registry showed that successful treatment and outcomes are likely regardless of the TAVI device.
- Incidence of unplanned post-TAVI PCI was rare (0.9%, median follow-up 191 days)
- Very high success rate (96.6%) for post-TAVI PCI
- No statistical difference in success rates for balloon-expandable versus self-expanding
- No statistical difference in the following factors among patients treated with two valve types
- Number of diagnostic or guiding catheters used
- Total fluoroscopy time
- Vascular access route during PCI
Gaining coronary access through any TAVI device can create complexities. But procedural considerations, commissural alignment, and effective case planning make the process feasible.
TAVI risks may include, but are not limited to, death, stroke, damage to the arteries, bleeding, and need for permanent pacemaker.
Additional resources
Explore commissural alignment
Understand the impact on final valve orientation and coronary artery overlap in a paper published in JACC by Dr. Tang, Dr. Zaid, and Dr. Fuchs, et al.
Hear from the experts
Dr. Harvey and Dr. Dauerman on procedural considerations for low-risk patients — including post-TAVI coronary access and commissural alignment.
Related pages
Explore our other procedural guidance and outcomes you can expect from the Evolut platform.
References
1
Harhash A, Ansari J, Mandel L, Kipperman R. STEMI After TAVR: Procedural Challenge and Catastrophic Outcome. JACC Cardiovasc Interv. July 11, 2016;9(13):1412–1413.
2
Stefanini GG, Cerrato E, Pivato CA, et al. Unplanned Percutaneous Coronary Revascularization After TAVR. JACC Cardiovasc Interv. January 25, 2021;14(2):198–207.