Stenting the Snorkel: PCI of a Restenosed Left Main Stent Placed for Coronary Obstruction after Valve in Valve TAVR

Acute coronary artery occlusion is a known compli-cation of transcatheter aortic valve replacement. One bailout strategy to treat acute coronary artery occlusion is deployment of a “snorkel” stent from the coronary artery behind the TAVR valve. While this approach will restore coronary artery patency, the long-term concern of this method is the ability to re-intervene on the stented coronary artery in the future. We demon-strate the complexity of re-intervention in a case of acute coronary syndrome due to ostial restenosis of a “snorkel” stent. the Medtronic self-expanding valves, which extend above the coronary ostia by design [4, 5]. The risk of coronary occlusion is increased for valve-in-valve pro-cedures compared to native aortic valves and may be up to 3.5% [4]. Additionally, the height of the coronary ostium is not as straightforward a guide as in a native valve, due to the variable relationship between the native annulus and the bioprosthetic leaflets, and careful imaging is critical in order to understand the patient-specific anatomy [6]. The most common treatment strategy in the event of coronary obstruction during TAVR is PCI with stent deployment, and this is associated with a >90% success rate [4]. This is generally performed by pulling back and deploying a stent that has been pre-delivered to the coronary artery. Another novel option is intentional laceration of the aortic valve leaflet (BASILICA) [7]. With TAVR becoming increasingly common as the indications have expanded, so too will patients returning with coronary artery disease requiring intervention after TAVR.