Figura 1. CT angiography with TAVI protocol showing a large infrarenal abdominal aortic aneurysm. (...

Figura 2. Step-by-step procedural images of same-session TAVI followed by EVAR. (A) Thoracic aortog...

Introduction

Aortic stenosis (AS) is the most prevalent clinically significant valvular heart disease in the elderly population and is associated with considerable morbidity and mortality when not treated in a timely and appropriate manner. Its estimated prevalence ranges from 2% to 7% in individuals over 65 years old, increasing progressively with age1, 2.

Abdominal aortic aneurysms (AAA) requiring treatment are defined as focal infrarenal aortic dilations with a diameter ≥5.0–5.5 cm or growth exceeding 0.6 cm per year. They affect approximately 4–8% of elderly adults3, 4.

While the concomitant presentation of AS and AAA is considered uncommon, it is likely underestimated — particularly in elderly patients with overlapping risk profiles. This is the case of a patient with severe AS and a large AAA, successfully treated with a combined single-session endovascular approach: transcatheter aortic valve implantation (TAVI) followed by endovascular aortic repair (EVAR).

Clinical case

A 79-year-old male with a history of hypertension and known coronary artery disease presented with progressive exertional dyspnea, NYHA functional class II–III, and reduced exercise tolerance.

A transthoracic echocardiography showed a left ventricular ejection fraction of 45% with global hypokinesis and severe AS with a valve area of 0.7 cm² and a mean transvalvular gradient of 40 mmHg.

A CT angiography (CTA) with TAVI protocol demonstrated an elliptical aortic annulus with a perimeter of 72.8 mm and an area of 412.6 mm², compatible with selection of a 29-mm Evolut™ PRO+ self-expanding prosthesis. The aortic root showed a mean Valsalva sinuses diameter of 29.4 mm with adequate coronary heights (left, 12.0 mm; right, 19.6 mm). Iliofemoral analysis showed minimum diameters ≥5.0 mm with no anatomical contraindication to percutaneous access. Incidentally, a large 70-mm infrarenal AAA was identified, with a 28-mm neck and no iliac artery involvement (Figure 1).

Procedure

Given the patient’s high surgical risk (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] 6%; European System for Cardiac Operative Risk Evaluation II [EuroSCORE II] 5%), a decision was made for a combined endovascular approach. The procedure was performed under neuroleptoanalgesia with conscious sedation using a titrated combination of midazolam and fentanyl, with preservation of spontaneous ventilation. Intravenous sodium heparin (70–100 IU/kg) was administered with serial activated clotting time (ACT) monitoring, maintaining ACT >250–300 seconds. As a renal protection strategy, protocolized endovenous hydration with isotonic crystalloid solution was administered before and after the procedure. Bilateral femoral access was obtained, and suture-mediated percutaneous closure devices were deployed, achieving successful final hemostasis. A 29-mm Evolut PRO+ self-expanding valve (Medtronic, Minneapolis, MN, USA) was implanted over a Confida Brecker 0.035-inch extra-support guidewire (Medtronic, Minneapolis, MN, USA) with rapid ventricular pacing at 180 beats per minute.

Following successful aortic valve implantation, a 6-Fr pigtail catheter was advanced via the left femoral artery to the suprarenal aorta. A Lunderquist extra-stiff 0.035-inch guidewire (Cook Medical, Bloomington, IN, USA) was introduced over a 6-Fr JR RunWay catheter (Cordis, Miami Lakes, FL, USA) through the right femoral access. An Endurant™ II bifurcated endograft (23-16-166 mm) was selected as the right-sided main body, compatible with a 21-mm proximal neck (21×29 mm), generating approximately 8–10% oversizing — adequate for proximal sealing without risk of infolding just below the left renal artery, with the distal end near the aortic bifurcation. Total length was concordant with preoperative measurements (L2 + L3R = 216 mm; L2 + L3L = 206 mm).

During retrieval of the main body delivery system nose cone, the pigtail catheter was inadvertently trapped and kinked, migrating partially into the prosthetic lumen. This complication was successfully resolved by advancing a partially inflated CODA elastomeric balloon catheter (Cook Medical, Bloomington, IN, USA) through the contralateral femoral access, straightening and advancing the pigtail catheter, and subsequently withdrawing it by means of a 0.035-inch guidewire.

Contralateral gate cannulation was performed using a JR catheter and a Starter guidewire (Medtronic). Iliac extensions were implanted (16-16-93 mm and 16-16-156 mm), followed by placement of the right-side extension (16-16-82 mm) and post-dilation with the CODA elastomeric balloon catheter. Total fluoroscopy time was 14 minutes for the TAVI procedure and 28 minutes for EVAR. Total iodinated contrast volume was 85 mL during TAVI and 105 mL during EVAR. Final angiography confirmed correct endograft expansion and complete aneurysm sac exclusion with no evidence of endoleak (types I–V) (Figure 2). Following the index procedure, the patient was discharged on dual antiplatelet therapy with aspirin and clopidogrel for 3 months.

Discussion

While the coexistence of severe AS and AAA is relatively uncommon, it poses a complex clinical scenario — particularly in the case of frail or high-surgical-risk patients. To date, and to the best of our knowledge, published clinical evidence supporting a simultaneous endovascular strategy remains limited5-8. Nevertheless, this combined approach may offer significant advantages over a staged strategy, including shorter hospital stay, a single anesthetic exposure, and reduced risk of periprocedural vascular complications.

Among the possible strategies, the sequence TAVI first, followed by EVAR, is widely considered the most appropriate in cases of concomitant AS and AAA. Performing TAVI first allows for hemodynamic stabilization by relieving left ventricular outflow tract obstruction, reducing afterload, improving cardiac output, and lowering perioperative risk. This sequencing is especially critical in patients with reduced left ventricular ejection fraction or symptomatic heart failure, in whom the physiological stress of EVAR alone could result in cardiovascular decompensation. Furthermore, implanting the aortic endograft prior to TAVI could create technical obstacles to retrograde advancement of the TAVI system, particularly in tortuous or heavily calcified aortas.

Cumulative exposure to iodinated contrast and ionizing radiation are additional essential management considerations. Contrast-induced nephropathy is a relevant concern in elderly patients or those with borderline renal function9. In our case, both procedures were performed in a single session with meticulous preoperative planning, optimized imaging protocols, and use of low-osmolarity contrast agents — measures that allowed for the total contrast load and fluoroscopy time to be within safe limits, minimizing renal risk and supporting an uncomplicated postoperative course.

From a technical standpoint, initiating the sequence with TAVI also reduces the likelihood of aortic injury during catheter manipulation in a pressure-overloaded, stenotic left ventricle. Conversely, performing EVAR first could acutely increase afterload, exacerbate AS symptoms, or even result in secondary hemodynamic decompensation. Additionally, the rigid metallic frame of the aortic endograft could interfere with transcatheter valve system advancement and deployment, adding procedural complexity10.

Taken all of these considerations into account, the TAVI-before-EVAR sequence offers multiple advantages over staged repair. While available clinical data are sparse and largely limited to isolated case reports, emerging experience supports its feasibility, safety, and potential benefits in carefully selected high-risk patients. Multidisciplinary Heart Team involvement remains essential to ensure optimal procedural planning tailored to each patient’s anatomical characteristics, comorbidities, and overall risk profile.

Conclusions

In selected patients with concomitant AS and AAA, a single-session endovascular approach — performing TAVI first, followed by EVAR — may be a safe and feasible therapeutic strategy. Until robust evidence becomes available, clinical judgment and multidisciplinary team-based decision-making remain fundamental to guiding individualized treatment planning in this complex patient population.

1. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368(9540):1005-11.

2. Ambrosy AP, Go AS, Leong TK, et al. Temporal trends in the prevalence and severity of aortic stenosis within a contemporary and diverse community-based cohort. Int J Cardiol. 2023;384:107-11.

3. Summers KL, Kerut EK, Sheahan CM, et al. Evaluating the prevalence of abdominal aortic aneurysms in the United States through a national screening database. J Vasc Surg. 2021;73(1):61-8.

4. Singh K, Bønaa KH, Jacobsen BK, et al. Prevalence of and Risk Factors for Abdominal Aortic Aneurysms in a Population-based Study : The Tromsø Study. Am J Epidemiol. 2001;154(3):236-44.

5. Sato Y, Horiuchi Y, Yahagi K, et al. Simultaneous transcatheter aortic valve implantation and endovascular aneurysm repair in a patient with very severe aortic stenosis with abdominal aortic aneurysm. J Cardiol Cases. 2018;17(4):123-5.

6. Koutsias S, Karaolanis GI, Papafaklis MI, et al. Simultaneous transcatheter aortic valve implantation and infrarenal aortic aneurysm repair for severe aortic stenosis and abdominal aortic aneurysm: Report of 2 cases and literature review. Vasc Endovascular Surg. 2020;54(6):544-8.

7. Marchi F, Cerillo AG, Rizza A, et al. Large Abdominal Aortic Aneurysm in a High-Risk Surgical Patient: Combined Percutaneous Transfemoral TAVI and EVAR Procedure. J Heart Valve Dis. 2015;24(3):310-2.

8. Gallitto E, Spath P, Faggioli GL, et al. Simultaneous versus staged approach in transcatheter aortic valve implantation for severe stenosis and endovascular aortic repair for thoracic and abdominal aortic aneurysm. Eur Jf Cardiothorac Surg. 2024;66(5).

9. Mehta A, Sale S, Capdeville M. The Deployment of Valve Academic Research Consortium 3 (VARC-3): New Endpoints, Broader Definitions, and Plenty of Unanswered Questions. J Cardiothorac Vasc Anesth. 2021 Dec;35(12):3463-6.

10. Zettervall SL, Schanzer A. ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms: A North American Perspective. Eur J Vasc Endovasc Surg. 2024;67(2):187-9.

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Combined endovascular treatment of severe aortic stenosis and abdominal aortic aneurysm: a case report

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