case_images: PMC10623418_01
case_images: (A) Basal aortography showed the diffuse aortic wall calcifications and very angulated aortic arch. (B-C) Double bilateral femoral punctures. (B) common and superficial right femoral sheaths, respectively for the cerebral embolic device (8F) and 20 mm snare (5F). (C) common and superficial left femoral sheaths, respectively for interventional access and ipsilateral femoro-femoral "wire protection" (5F). (D) Aortography showed multiple calcific stenosis of both iliac-femoral arteries. (E-F) The 18F Cook Introducer (white arrowhead) was advanced via a brachiofemoral "through-and-through wire technique" after dilatation of ostial left common iliac artery stenosis with a semi-compliant 8 mm balloon (white arrow).
case_images: fcvm-10-1213817-g001.jpg
case_images: PMC10623418_01_fcvm-10-1213817-g001.jpg
case_images: F1
case_images: PROM 8%). Pre-operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, "gothic" aortic arch (AA) and multiple calcific stenosis of both iliac-femoral vessels, severely tortuous (Figures 1, 3-4, Supplementary Figure S1). THV has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the "gotic" and calcific AA (Figures 1, 3, Supplementary Figures S3-S5). The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses (Figure 1, panels B-C).
case_images: Procedural steps -2. (A) Aortography showed calcific very angulated aortic arch. (B) Aortography in the "virtual basal plane" view with pre-mounted snare. (C,D) The snared valve is pulled (yellow arrow), detached from the aortic wall under complete cerebral protection and (E) advanced through ascending aorta. (F) The final angiography documented a good result without significant paravalvular leak.
case_images: fcvm-10-1213817-g002.jpg
case_images: PMC10623418_01_fcvm-10-1213817-g002.jpg
case_images: F2
case_images: PROM 8%). Pre-operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, "gothic" aortic arch (AA) and multiple calcific stenosis of both iliac-femoral vessels, severely tortuous (Figures 1, 3-4, Supplementary Figure S1). TriGuard  system and delivery advancement "snaring-assisted" (Figures 2, Supplementary Figures S3-S5). The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino-tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp) (Figures 3, 4). THV was advanced on the snared guidewire, and the tip of the THV was ensnared and then pulled in order to be detached from the calcified wall of the ascending aorta, allowing the valve to be steered ("Chaperoned") through them moreover without any interference with the CP system ("Top Hat") (Figure 2) (Supplementary Movies S1-S4). There were no complications related to the snaring of THV, conversely the snaring maneuver has facilitated the "atraumatic" transit of the THV into the aortic arch. Figure S2). Finally no complications related to the vascular accesses occurred.
case_images: Pre-Procedural multislice computed tomographic evaluation. Pre-operative thoraco-abdominal computed tomography angiography showed (A) an aortic annulus perimeter of 72.7 mm (area of 410,6 mm2), (B-D,E) an aortic valve severely calcified, and (C) a left ventricular outflow tract (LVOT) perimeter of 75.6 mm with elliptical shape (area of 422,6 mm2), (F) "gothic" and calcific aortic arch and (G) multiple calcific stenosis of both iliac-femoral vessels, severely tortuous.
case_images: fcvm-10-1213817-g003.jpg
case_images: PMC10623418_01_fcvm-10-1213817-g003.jpg
case_images: F3
case_images: PROM 8%). Pre-operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, "gothic" aortic arch (AA) and multiple calcific stenosis of both iliac-femoral vessels, severely tortuous (Figures 1, 3-4, Supplementary Figure S1). TriGuard  system and delivery advancement "snaring-assisted" (Figures 2, Supplementary Figures S3-S5). The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino-tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp) (Figures 3, 4). THV has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the "gotic" and calcific AA (Figures 1, 3, Supplementary Figures S3-S5). The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses (Figure 1, panels B-C).
case_images: Pre-Procedural multislice computed tomographic evaluation: aortic calcifications. MIP-reconstruction of the thoraco-abdominal CT angiography showed the massive calcifications of the ascending aorta and the sino-tubular junction.
case_images: fcvm-10-1213817-g004.jpg
case_images: PMC10623418_01_fcvm-10-1213817-g004.jpg
case_images: F4
case_images: TriGuard  system and delivery advancement "snaring-assisted" (Figures 2, Supplementary Figures S3-S5). The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino-tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp) (Figures 3, 4). THV has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the "gotic" and calcific AA (Figures 1, 3, Supplementary Figures S3-S5). The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses (Figure 1, panels B-C).