LAUSR

An 83-year-old woman with severe aortic stenosis underwent transfemoral transcatheter aortic valve implantation (TF-TAVI). Although pre-procedural computed tomography (CT) reveals calcification in both iliac arteries (Panel A), a left-side access route seemed feasible. A 14Fr e-Sheath was easily inserted; whereas, it was difficult to advance a 23-mm SAPIEN-3 valve (Edwards Lifesciences, California, USA) through the e-Sheath. The valve was deployed within the aortic valve. After we removed the e-Sheath, the patient’s blood pressure suddenly decreased. Angiography revealed extravasation of contrast media in the left external iliac artery (Panel B). To rescue her from hemorrhagic shock, 7.0/39 mm and 7.0/59 mm balloon-expandable VIABAHN (GORE, Delaware, USA) stent grafts were implanted to stabilize the ruptured iliac artery (Panel C). After post-dilatation by stent-graft balloon (7.0/59 mm), hemostasis was confirmed at the early and delayed phases of contrast injection (panels D–E). The patient’s hemodynamic status recovered and she was moved to the intensive care unit. However, her blood pressure gradually decreased 4 h after TF-TAVI. A huge hematoma (Panel F) and minor continuous leakage of contrast from the prior rupture site were revealed by contrast CT (Panel G). Angiography revealed a small extravasation of contrast material through the overlapping stent grafts in the early phase (Panel H) and gradual expansion during the delayed phase (Panel I). To achieve hemostasis for rebleeding, we implanted an additional bare-metal Omnilink 8.0/29 mm stent (Abbott, Santa Clara, USA), which was larger than reference vessel diameter to increase the radial force of stent grafts. There was no subsequent re-bleeding in either the early or delayed phase (Panels J–K). The patient was discharged 14 days after TF-TAVI without any recurrent bleeding events. Percutaneous vascular repair using a balloon-expandable stent graft is feasible in cases of vascular rupture during TFTAVI. Nonetheless, we experienced a unique case of delayed re-bleeding through balloon-expandable stent grafts. The mechanism of re-bleeding was considered the acute recoil of stent grafts, stent graft mal-apposition, and/or retrograde blood flow from the branch of the iliac artery, although we could not find conclusive evidence thereof. To prevent such complications, patients who undergo this procedure should be monitored carefully, even after a successful bail-out intervention (Fig. 1).