Scaffold technique for endovascular rescue of embolized transcatheter aortic valve with type B aortic dissection

Transcatheter aortic valve replacement (TAVR) has become a transformative therapy for patients with severe aortic stenosis, offering a minimally invasive alternative to surgical valve replacement across all risk categories. Although outcomes are generally favorable, rare but potentially life-threatening complications such as prosthetic valve embolization and aortic dissection can pose significant challenges, even for experienced multidisciplinary cardiovascular teams. We report the case of an 87-year-old man with severe aortic stenosis and multiple comorbidities who underwent elective transfemoral TAVR using a 26-mm Edwards SAPIEN 3 Resilia valve. Intraoperative pacer malfunction during rapid pacing resulted in valve embolization into the ascending aorta. The valve was maneuvered and repositioned into the descending thoracic aorta, after which a second valve was implanted successfully at the native annulus. The patient subsequently developed new-onset chest and back pain on postoperative day 1. Computed tomography angiography confirmed a DeBakey type B aortic dissection originating at the level of the embolized valve and extending to the diaphragm. A two-step thoracic endovascular aortic repair (TEVAR) was performed using a bare metal Terumo Relay stent to scaffold the embolized valve, followed by a tapered covered stent to seal the dissection. We propose referring to this hybrid approach as the scaffold technique, a novel endovascular strategy to simultaneously stabilize an embolized transcatheter valve and treat coexisting aortic pathology. Valve embolization after TAVR is rare, with an incidence ranging from 0.3% to 1.7%; type B dissection is even more infrequent. The literature supports only a limited number of similar cases managed with TEVAR, and even fewer with a formalized dual-stent strategy, as outlined here. Device selection is critical; TEVAR platforms such as the Terumo Relay, Gore TAG, Medtronic Valiant, and Cook Zenith Alpha each offer unique deployment profiles and structural advantages. This case highlights the importance of rapid recognition, anatomical precision, and endovascular innovation in managing high-risk TAVR complications. This case underscores the vital role of vascular surgery in the contemporary TAVR era. It illustrates the scaffold technique as a safe, effective, and reproducible solution for patients presenting with valve migration, descending thoracic aortic dissection, and limited proximal landing zone where conventional strategies may be insufficient.