Covered-Stent Migration During Same-Session Aortic Isthmus Repair and Bicuspid Aortic Valve TAVR

Fixed obstruction at the aortic isthmus may preclude transfemoral transcatheter aortic valve replacement (TAVR). Covered-stent implantation can restore large-bore access, but immediate passage of balloons and delivery systems through a newly implanted stent may expose it to longitudinal traction. Secondary stent migration during withdrawal of a valvuloplasty balloon and its intraluminal balloon-assisted rescue have not been well characterized. An 87-year-old man with New York Heart Association class III symptoms had severe bicuspid aortic stenosis (peak velocity, 4.4 m/s; mean gradient, 48 mmHg; valve area, 0.65 cm2; left ventricular ejection fraction, 55%) and a focal juxtaductal aortic-isthmus stenosis with a peak-to-peak gradient of 32 mmHg. Because of high surgical risk and unfavorable alternative access, same-session covered-stent treatment followed by transfemoral TAVR was selected. A 12 × 29-mm Advanta V12 covered stent was deployed and flared using an 18-mm noncompliant balloon. After aortic-valve predilation with a 23-mm noncompliant balloon, the stent migrated distally during balloon withdrawal. Guidewire access was preserved, and the stent remained coaxial. The balloon was recentered within the migrated stent and partially reinflated, allowing the balloon and stent to be advanced proximally as a single unit. After restoration and re-expansion of the stent, a 23-mm Myval valve was implanted successfully. Final transvalvular and isthmic gradients were 8 and 5 mmHg, respectively, with trivial paravalvular regurgitation and no aortic injury. The patient was discharged on day 3 and remained in NYHA class I at 6 months. Withdrawal of a large valvuloplasty balloon may cause secondary migration of a newly implanted aortic-isthmus stent. When guidewire access, coaxial alignment, and structural integrity are preserved, controlled intraluminal balloon-assisted repositioning may provide an effective bailout while maintaining transfemoral access.