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Page 8 of 19 Khokhar et al. Mini-invasive Surg 2022;6:2 https://dx.doi.org/10.20517/2574-1225.2021.97

Figure 3. Coronary protection with “chimney stenting” technique. Valve-in-valve procedure for a patient at high risk for coronary
obstruction (low-lying coronary ostia and narrow sinuses). (A) Left coronary ostium was engaged and a wire and stent (yellow star)
placed distally in the artery prior to valve deployment. (B) Following valve deployment, the stent was retracted and (C) implanted
adjacent to the transcatheter valve. (D) The CT reconstruction image shows half the stent placed in the ostium and the other half
protruding into the aorta.

have been reported in other smaller series [79,80] . The key advantage of the BASILICA procedure is the
possibility of avoiding stent implantation, which mitigates the need for prolonged DAPT therapy and avoids
potential stent-related complications such as under-expansion or restenosis.

Management of coronary obstruction
The diagnosis of CO is usually immediately apparent and can be confirmed by aortography and ECG
evaluation, with echocardiography utilized to evaluate for regional wall motion abnormalities if doubt
persists. CO usually occurs following post-dilatation or during initial deployment with a BEV. If CO occurs
following deployment of a SEV, then, depending on the type of valve and stage of deployment, the device
can be recaptured immediately to restore flow. If repositioning is not feasible, then immediate stenting
should be attempted and if unsuccessful, then an inflated balloon or snare can be used to pull up a SEV into
the ascending aorta. Hemodynamic support, including use of ECMO, should be considered early to