The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Axillary Artery Occlusion after TAVR

A B

A
n 84-year-old man had sudden onset of severe pain and weak- Alexander Kille, M.D.
ness in the right arm 7 days after undergoing transcatheter aortic-valve Willibald Hochholzer, M.D.
replacement (TAVR) for symptomatic aortic stenosis. Physical examination University Heart Center Freiburg–
showed a pale right forearm, nonpalpable right radial and brachial pulses, and Bad Krozingen
reduced strength in the right arm. Three-dimensional computed tomographic Bad Krozingen, Germany
alexander.kille@
angiography revealed an occlusion of the right axillary artery (Panel A, arrow), and universitaets-herzzentrum.de
a two-dimensional angiogram showed hypoattenuated thickening of the noncoro-
nary and left coronary aortic leaflets (Panel B, arrows). Surgical thrombectomy
was performed, and a fresh thrombus was removed. Transesophageal echocardiog-
raphy that was performed after thrombectomy revealed a thickened noncoronary
aortic leaflet but no intracardiac thrombus. The transvalvular gradient was mea-
sured at 15 mm Hg, an increase from 8 mm Hg measured after TAVR. After
thrombectomy, the pain and weakness in the patient’s right arm resolved. Aspirin
and clopidogrel, which had been the dual antiplatelet therapy initiated after TAVR,
were discontinued, and treatment with an oral anticoagulant was initiated.
DOI: 10.1056/NEJMicm1913768
Copyright © 2020 Massachusetts Medical Society.

n engl j med 382;2 nejm.org January 9, 2020 179

The New England Journal of Medicine
Downloaded from nejm.org by AJI PANGESTU J on January 21, 2020. For personal use only. No other uses without permission.
Copyright © 2020 Massachusetts Medical Society. All rights reserved.