FIGURE LEGEND
Figure 1: Iliofemoral vessels evaluation. Bilateral reconstructions and snake view of the iliofemoral vessels and descending abdominal aorta. This patient had heavy calcifications of the more distal vessels and so an alternative cannulation site for AAP needed to be found. A cannula with a 6 mm diameter would not even fit into the common femoral artery and this could lead to obstruction and ipsilateral limb ischemia. We also believe that cannulation and RAP of the femoral vessels in a patient with such anatomical characteristics would distinctly increase the risk of perioperative stroke and dissection.
Figure 2: Evaluation of the right axillary artery as cannulation site for antegrade arterial perfusion. If cannulation of the femoral vessels is not an option during case planning for RALT-MIAVR, the right axillary artery should be considered as an alternative cannulation site. In this case the right axillary artery presented with a diameter of 7 mm without calcifications and atherosclerotic burden.
Figure 3: RALT-MIAVR case awareness. A) Heavily calcified ascending aorta and aortic arch, not suited for central cross-clamping.B) Snake view of the right iliofemoral and descending abdominal aortic axis of two different patients. The left picture showing a chronic type B dissection and aneurysmal aortic disease. The picture on the right side outlines atherosclerotic disease and soft plaque buildup. A RAP strategy in these patients would not be suitable. C)Although referred to our institution for RALT-MIAVR, we conducted a TAx-TAVI in this patient. The iliofemoral vessels and abdominal aorta portrayed too much atherosclerosis and analysis of the aortic annulus using 3menso software showed a rather small annulus with low implantation of the right coronary ostium (1cm). D) Examination of the anatomy of the aortic root revealed an aberrant RCx. E)The hockey-puck perspective of the aortic valve exhibits extensive calcification of the leaflets, the annulus even reaching into the LVOT. In this patient MAC of the mitral valve was also found. The total calcium scoring in this patient was 1789.2 mm3.F) Three-dimensional reconstructions of the bony structures of the thoracic cage allows the surgeon to precisely select the right ICS as his main working port for RALT-MIAVR. In this particular case the third ICS (green dotted line) would be the optimal access site, whereas the second ICS (red dotted line) would be too cranial.