Anatomical Reasons for Technical Failure of Dual-Filter Cerebral Embolic Protection Application in TAVR: A CT-Based analysis

Objectives: The dual-filter cerebral embolic protection (CEP) device is increasingly used during transcatheter aortic valve replacement (TAVR). However, complex vascular anatomy may challenge CEP deployment. We aimed to analyze the impact of anatomical characteristics on technical device failure during CEP application.

Methods: We retrospectively analyzed the multislice computed tomography scans (MSCT) of all patients undergoing TAVR with dual-filter CEP between 2016 and 2020 (n = 92). The analysis included the assessment of aortic arch anatomy and the angles of the supra-aortic arteries. Brachiocephalic and left common carotid artery tortuosity index was determined by calculating a distance factor: ([(center-line distance)/(straight-line distance) −1] × 100). Right subclavian tortuosity index was defined as the sum of all tortuosity angles along its course. MSCT data was assessed for statistical significance among TAVR patients with success of CEP deployment and among patients with technical device failure.

Result: Procedural success of dual-filter CEP application was obtained in 83 patients (90.2%). Technical device failure in 9 patients (9.8%) was due to the infeasibility to perform correct deployment of both filters (n = 7) and to obtain peripheral radial access (2). Patients with a technical failure of CEP application had a higher right subclavian tortuosity index (217 [92–324] vs. 150 [42–252], p = 0.046), a higher brachiocephalic tortuosity index (27 [5–51] vs. 10 [0–102], p = 0.033) and a larger angulation of the brachiocephalic artery (59 [22–80] vs. 39 degrees [7–104], p = 0.014) compared with patients with successful CEP deployment. By receiver operating curve analysis, a brachiocephalic angle greater than 59 degrees and a brachiocephalic tortuosity index greater than 26 were identified as predictors for technical device failure. No differences in aortic arch anatomy or common carotid artery tortuosity were detected between the groups.

Conclusion: Brachiocephalic tortuosity was found to be associated with technical device failure of dual-filter CEP application. Standardized preoperative calculation of index and angulation might help to anticipate possible difficulties during CEP deployment.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
19 February 2021