VECTOR: First Percutaneous Aorto-Coronary Bypass Case, a New Conceptual Approach

Coronary obstruction represents one of the most severe complications associated with transcatheter aortic valve implantation, particularly in valve-in-valve scenarios involving surgical bioprostheses, narrow aortic sinuses, low coronary ostia, and severely calcified leaflets. In this setting, several preventive strategies have been developed over recent years, including BASILICA, UNICORN, CATHEDRAL, and snorkel stenting. However, these complex techniques may be unfeasible in the presence of specific anatomical limitations.

Bruce et al., from Emory University Hospital (Atlanta, USA), described the first-in-human case of an extra-anatomical percutaneous aorto-coronary bypass, termed VECTOR (Ventriculo-Coronary Transcatheter Outward Navigation and Re-entry), developed with the specific aim of preventing left main coronary artery obstruction during transcatheter valve implantation. This approach introduces a relevant conceptual shift, as it does not seek to modify the valve or protect the native coronary ostium, but rather to functionally relocate coronary blood flow through the creation of a new percutaneous pathway.

The procedure was performed in a 67-year-old patient with severe degeneration of a surgical aortic bioprosthesis (25 mm Magna Ease), a history of prior mitral valve replacement (29 mm Epic, degenerated and treated with valve-in-valve using Sapien 3 Ultra), advanced ventricular dysfunction, and multiple comorbidities rendering the patient prohibitive for conventional surgery, with a Society of Thoracic Surgeons–predicted operative mortality of 13%. Computed tomography planning demonstrated an extreme risk of coronary obstruction, with critically short valve-to-coronary distances and confluent leaflet calcification, thereby excluding any leaflet modification strategy. The procedure was performed under general anesthesia with venoarterial extracorporeal membrane oxygenation support.

Read also: Comparison of strategies: NMA of IVUS, OCT, or angiography in complex lesions.

VECTOR in TAVI: effective coronary perfusion through a percutaneous bypass

From a technical standpoint, the strategy combined transcatheter electrosurgery with advanced concepts derived from chronic total occlusion recanalization. The procedure consisted of creating an extra-anatomical bypass between the aorta and the left main coronary artery using covered stents. The distal anastomosis was achieved through intentional exit from the left main coronary artery into the pericardial space, assisted by stent-and-stingray–type techniques. This involved aorto-venous externalization through septal perforation and capture in the right ventricle with a snare, followed by retrograde advancement of a dual-lumen microcatheter to access the pericardial space. The proximal anastomosis was performed by electro-surgical exit from the aorta into the pericardial space and retrograde advancement of the coronary guidewire toward the pericardial guiding catheter. The resulting graft, composed of two overlapping PK Papyrus stents, provided adequate coronary perfusion with functional exclusion of the native ostium.

Following bypass creation, valve implantation was performed, resulting in compression of the anchoring stent at the native ostium due to displacement of the surgical leaflet. Follow-up imaging at six months confirmed graft patency and occlusion of the native left main coronary artery between the transcatheter valve and the distal anastomosis. The patient demonstrated a favorable clinical course during follow-up.

Read also: Dynamic Coronary Roadmap: does it really help reduce contrast use?

Conclusion: VECTOR expands the structural interventional approach in TAVI

This first-in-human report demonstrates the feasibility of a fully percutaneous aorto-coronary bypass as a preventive strategy against coronary obstruction in patients without surgical alternatives. Beyond its technical complexity, VECTOR expands the conceptual spectrum of structural intervention by showing that, in highly selected cases, the solution may lie in redefining the coronary blood flow pathway through a percutaneous approach.

Original Title: Percutaneous Aorto-Coronary Bypass Graft to Prevent Coronary Obstruction Following TAVR: First Human VECTOR Procedure.

Reference: Bruce CG, Babaliaros VC, Paone G, Gleason PT, Halaby RN, Khan JM, Rogers T, Richter E, Lederman RJ, Greenbaum AB. Percutaneous Aorto-Coronary Bypass Graft to Prevent Coronary Obstruction Following TAVR: First Human VECTOR Procedure. Circ Cardiovasc Interv. 2026 Jan 6:e016130. doi: 10.1161/CIRCINTERVENTIONS.125.016130. Epub ahead of print. PMID: 41492768; PMCID: PMC12778967.