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Page 6 of 12 Tagliari et al. Vessel Plus 2020;4:16 I http://dx.doi.org/10.20517/2574-1209.2020.05

Despite no clear recommendation available, the idea of combining TAVI with abdominal endovascular
aneurysm repair (EVAR) seems appealing. Some potential benefits of simultaneous approaches are as
follows: to prevent a potential aortic rupture related to the abrupt rise in blood pressure after relieving
aortic valve gradient; to reduce vascular complications by accessing the artery a single time; and to shorten
length of hospital stay by combining the two strategies in a single procedure [48,49] .

[50]
[49]
Regarding which specific procedure should be done first, Sato et al. and Mauri et al. prefer to perform
[51]
TAVI before EVAR, while Natour et al. advocate starting with EVAR and then to use the same sheaths
and wires for the subsequent TAVI.
Performing EVAR first has the advantage of reducing the risk of vascular dissection caused by crossing the
aorta with the valve delivery system and preventing aneurysmal sac lesion due to sudden blood pressure
rise following TAVI. Furthermore, the increased clot burden within the aneurysmal sac and the consequent
risk of distal embolization may be an additional reason to prefer doing EVAR first. On the other hand,
performing TAVI first would avoid the risk of crossing the aortoiliac prosthesis, as well as reducing the risk
of local thrombosis due to a large EVAR sheath prolonged time within peripheral vessels .
[50]
Another emerging possibility is combining TAVI with thoracic endovascular aortic repair (TEVAR). In
[52]
2014, Komlo et al. reported the first case of a single-stage TAVI and TEVAR in a patient with critical
AS and descending thoracic aorta aneurysm. In this case, direct transaortic access via minimally invasive
partial sternotomy was chosen.

Furthermore, a relatively new concept is to treat the aortic valve and the ascending aorta together, using a
special proximal transcatheter aortic valve connected to an uncovered stent-graft portion, called the “endo
Bentall” concept. Unquestionably, this is an exceptional procedure, indicated only in highly selected cases,
but it shows that even the ascending aorta could be suitable for totally endovascular interventions [53,54] .

LEFT ATRIAL APPENDAGE OCCLUSION
Atrial fibrillation (AF) occurs in more than 10% of octogenarians, and it is the most common arrhythmia
[55]
in the TAVI population . In the first PARTNER cohorts, chronic AF was present in 32.9% of inoperable
[1]
[2]
ones and in 40.8% of high-risk patients who underwent TAVI . Compared to sinus rhythm, AF was
[56]
associated with double 1-year mortality (26.2% vs. 12.9%) .
Regardless of the type (paroxysmal, persistent, or permanent), AF is a strong predictor of stroke , and it is
[57]
[58]
independently associated with late cardiovascular morbidity and mortality after TAVI . The explanation
for these risks goes beyond its thromboembolic potential; it is also linked to the risk of major bleeding due
[59]
to oral anticoagulation (AF treatment) plus dual antiaggregation (indicated after TAVI) .
Although there is a lack of evidence supporting the best strategy for stroke prevention in TAVI patients
with pre-existing AF, the left atrial appendage occlusion (LAAO) strategy, especially in patients with
high risk of bleeding, could be an attractive option. The main advantage of combining LAAO with TAVI
is to provide a treatment that has proven to prevent stroke with efficacy similar, or even superior, to
warfarin [60,61] .

It is important to remember, however, that LAAO mitigates only the risk of embolization of thrombi
formed inside the left atrial appendage, having no effect on clots formed in the valve, or on calcium
[62]
embolization due to TAVI advancement or positioning. To try to cover these other factors, Gafoor et al.
suggest that the use of smaller sheaths, better delivery systems, and easier-to-position devices, besides
carotid protection systems, may provide more complete stroke prevention during TAVI.