Sheathless Transcaval Transcatheter Aortic Valve Implantation Through an Abdominal Aortic Graft

An 82-year-old patient presented with severe symptomatic aortic stenosis, a high surgical risk profile, and a history of abdominal aortic replacement. Arterial access vessel conditions precluded transarterial transcatheter aortic valve implantation (TAVI). Transcaval access through the aortic graft was achieved; however, tortuosity and resistance at the graft entry site hampered insertion of the introducer sheath and delivery system. Transcaval TAVI without a sheath was contemplated with the expectation of aortocaval fistulous decompression of blood around the TAVI catheter. Hemodynamic measures remained stable, and the valve was successfully implanted. This case illustrates the feasibility of sheathless transcaval TAVI without relevant hemodynamic compromise.