Cardiologists perform first procedure of its kind to prevent coronary obstruction after TAVR
A team of cardiologists have made a bit of history, performing the first interventional procedure of its kind to prevent coronary obstruction after transcatheter aortic valve replacement (TAVR) in a patient who could not undergo leaflet modification. The group shared its experience in Circulation: Cardiovascular Interventions.[1]
“Coronary artery obstruction is a devastating and frequently fatal complication of TAVR,” wrote senior author Adam B. Greenbaum, MD, a structural heart specialist with Emory University Hospital in Atlanta, and colleagues. “Leaflet modification techniques, such as BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction), UNICORN (Undermining Iatrogenic Coronary Obstruction With Radiofrequency Needle), and CATHEDRAL (CATHeter Electrosurgical Debulking and RemovAL), or snorkel stenting may not be suitable in excessively calcified leaflets and in a very narrow aortic root with low coronary ostia. Ventriculo-coronary transcatheter outward navigation and reentry (VECTOR) is a closed-chest, transcatheter, coronary ostial bypass procedure recently reported in animals. VECTOR accomplishes extra-anatomic bypass that relocates the coronary artery ostium safely away from transcatheter heart valve interference using commercial covered stents and catheter techniques resembling retrograde chronic total occlusion revascularization.”
The patient for this case was a 67-year-old male who had a history of undergoing both aortic and mitral valve replacement. The patient presented with decompensated heart failure from severe stenotic degeneration of his bioprosthetic aortic valve. He also had a history of end-stage renal failure that required hemodialysis, nondisabling stroke, severe nonischemic cardiomyopathy and severe peripheral arterial disease (PAD) in the form of left critical climb ischemia. His right leg, meanwhile, had recently been amputated due to his PAD.
Redo valve replacement surgery appeared to be incredibly risky, the authors explained, because of the man’s significant comorbidities; rehabilitation following treatment seemed unlikely at best. Also, cardiac CT results indicated there was an “extreme risk” of left coronary artery obstruction. The right coronary, on the other hand, showed no signs of obstruction.
“The bioprosthetic leaflets had heavy confluent calcification and no calcium-free traversal window to permit BASILICA, UNICORN, or CATHEDRAL,” the authors wrote. “Snorkel stenting was unlikely to be successful because of the high risk for stent compression in the narrow sinus. With no other feasible options, the patient was counseled extensively on, and consented to, VECTOR coronary artery bypass of the left main stem, despite explicitly high risk.”
![A team of cardiologists have made a bit of history, performing the first VECTOR procedure to prevent coronary obstruction after transcatheter aortic valve replacement (TAVR) in a patient who could not undergo leaflet modification. The group shared its experience in Circulation: Cardiovascular Interventions.[1]](https://cardiovascularbusiness.com/sites/default/files/2026-01/screenshot_2026-01-08_at_3.00.34_pm.png)
A) Before TAVR implantation, the native left main stent (asterisk) is seen within the SAVR valve frame post (yellow arrowhead) and the VECTOR extra-anatomic bypass (white arrowhead) cephalad. B) During valve deployment, the native left main stent is longitudinally compressed by the displaced left-coronary cusp (LCC) leaflet (white arrowhead). C) Aortic root angiography showing a lucent line (white arrowhead) created by the LCC leaflet between valve frames and left main ostium/stent. The lucent line is in contact with the stent and extends to the sino-tubular junction, indicating coronary obstruction. D) Maximum-intensity-projection CT from postprocedure day one shows occlusion of the native left main stent (white arrowhead), which otherwise might allow competitive flow. Images and captions courtesy of Greenbaum et al. and Circulation: Cardiovascular Interventions.
Greenbaum and colleagues detailed the complex procedure at length, noting that the patient was put under general anesthesia and elective veno-arterial extracorporeal membrane oxygenation. Using a series of devices from multiple manufacturers, the care team successfully relocated the coronary ostium using techniques similar to retrograde CTO revascularization.
After the VECTOR procedure was complete, the group went on to perform TAVR with a 23 mm balloon-expandable valve post dilatated with a 23 mm noncompliant balloon. The total procedure time was 8 hours and 40 minutes, and the total fluoroscopy time was 226 minutes.
Overall, the VECTOR procedure was a clear success. The patient is still doing well after six months.
“This case demonstrates the first percutaneous aorto-coronary bypass procedure that successfully prevented coronary obstruction following TAVR in a patient ineligible for leaflet modification,” the authors wrote.
The group closed by emphasizing that many more VECTOR procedures still need to be performed to ensure it is a safe, effective treatment option for these high-risk heart patients.
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.