*Introduction

The prevalence of concomitant aortic aneurysms involving the thoracic and abdominal aorta in patients with severe aortic valve stenosis has increased in the elderly population, and is reported in approximately 6% of patients undergoing transcatheter aortic valve implantation (TAVI).1-3 Currently, there are no established recommendations regarding the optimal management of these patients, rendering their treatment particularly challenging.

Historically, management of patients requiring aortic valve replacement (AVR) in the presence of an aortic aneurysm has favored a staged approach, with simultaneous repair reserved for cases involving large or symptomatic aneurysms, primarily due to concerns regarding the increased risk of aneurysm rupture following open AVR.4 In recent years, in an effort to mitigate perioperative mortality and the invasiveness associated with combined open procedures, a single-stage approach consisting of TAVI followed by thoracic or endovascular aortic aneurysm repair (TEVAR) has emerged as an attractive and less invasive alternative.5-7 The aim of the present review is to summarize the available published cases of patients with concomitant aortic aneurysms undergoing TAVI, treated either in simultaneous or staged manner.

METHODS

Design and registration

The present systematic review was designed and reported in accordance with the Preferred Reporting Items for Systematic reviews (PRISMA) statement (Figure 1).

Eligibility criteria

Observational cohort studies (prospective or retrospective), and case series/report studies, published in English, and reporting data on TAVI and TEVAR or EVAR, were considered eligible. Studies which provided data on hybrid procedures (open aortic valve replacement +TEVAR or EVAR), or those with TAVI and open repair of thoracic and abdominal aortic aneurysm were excluded.

Search strategy

A thorough literature search was conducted in MEDLINE (via PubMed; 1966 to November 2025), EMBASE (via Ovid; 1980 to November 2025), the Cochrane Central Register of Controlled Trials (CENTRAL) (through November 2025), and Google Scholar (through November 2025). A snowball process of the reference lists from the eligible studies was performed after the retrieval of relevant reports from the databases searches. The following search items, including expanded Medical Subject Headings (MeSH) terms were used in various combination: ((transcatheter aortic valve implantation) OR (replacement)) AND (aneurysm) AND (endovascular aortic repair). Figure 1 depicts the eligible studies available in the literature, including 22 studies2, 5, 7-26 with TAVI and EVAR and 10 studies5, 6, 27-34 with TAVI and TEVAR. Unfortunately, most of the included studies were case reports (n = 24),3, 6, 8, 10-17, 22-24, 27, 28, 30-35 while only three studies2, 5, 7 included more than 10 patients and six studies9, 20, 21, 25, 26, 29 were small case series comprising six or fewer patients. One study reported outcomes on TAVI and TEVAR or EVAR.5 Owing to the limited sample sizes and heterogeneity of the available data, no formal statistical analysis was performed in the present review.

Definitions

Major adverse events were defined as all-cause mortality, myocardial infarction, respiratory failure requiring prolonged (>24 hours from anticipated) mechanical ventilation or reintubation, renal function decline resulting in >50% reduction in baseline eGFR or new-onset dialysis, bowel ischemia requiring surgical resection or not resolving with medical therapy, major stroke, and paraplegia.36

All events that occurred intraoperatively or within 30 days postoperatively were defined as early outcomes, whereas RTAD events occurring more than 30 days after surgery were defined as late outcomes.

Pathophysiological Considerations

Severe aortic valve stenosis and aortic aneurysmal disease frequently coexist in elderly patients, sharing common risk factors such as advanced age, hypertension, atherosclerosis, and degenerative changes of the aortic wall. The presence of severe aortic stenosis leads to chronic pressure overload of the left ventricle, resulting in reduced cardiac output and altered aortic hemodynamics. These changes may partially mask the true hemodynamic stress exerted on the aneurysmal aortic wall prior to valve intervention.37, 38 Relief of aortic stenosis following aortic valve replacement, particularly after TAVI, results in an abrupt increase in cardiac output and systolic blood pressure. This sudden hemodynamic shift may increase wall shear stress and transmural pressure within the aneurysm, potentially predisposing to aneurysm expansion or rupture, especially in large or unstable aneurysms.39, 40 This phenomenon has historically raised concerns regarding the safety of isolated valve replacement in patients with concomitant aortic aneurysms. Furthermore, manipulation of the aorta during valve procedures, including catheter and device passage through aneurysmal segments, may increase the risk of embolization, dissection, or rupture, particularly in extensively diseased or thrombus aorta.41 These risks underscore the importance of meticulous preprocedural imaging and planning.

Conversely, endovascular aortic repair (EVAR or TEVAR) stabilizes the aneurysmal segment by excluding it from systemic arterial pressure, potentially reducing the risk associated with subsequent increases in cardiac output following valve intervention. For this reason, combined or staged endovascular and transcatheter strategies have been increasingly considered to mitigate these opposing pathophysiological forces.42

Understanding the complex hemodynamic interplay between aortic valve stenosis and aneurysmal disease is crucial for optimizing procedural sequencing and minimizing perioperative risk. This interplay forms the physiological basis for contemporary combined treatment strategies using TAVI and endovascular aortic repair.

RESULTS

A. Thoracic endovascular aneurysm repair and Transcatheter aortic valve implantation

In the present review, ten studies,5, 6, 27-34 comprising eight case reports6, 27, 28, 30-34 and two case series5, 29 with a total of 18 patients reported outcomes following combined thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) (Table 1). The mean patient age was 80 years (range, 60-88 years). The mean maximum aortic diameter was 66 mm (range, 20-90 mm). Twelve patients underwent a single-stage procedure, whereas five patients were treated using a staged approach.

The Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) was used in six studies29-34 while in two studies6, 27 was selected the Evolut Pro (Medtronic, Minneapolis, MN, USA). Regarding the type of thoracic aortic endografts used, the c-TAG device (W.L. Gore & Associates, Flagstaff, AZ, USA) was used in four patients,6, 29, 30, 33 the Valiant Captivia device (Medtronic, Minneapolis, MN, USA) in two patients,27, 31 and the Najuta thoracic stent graft (Kawasumi Laboratories, Inc., Tokyo, Japan) in two patients.28, 32 In the remaining cases, the type of thoracic endograft was not specified.

Early outcomes

One patient died during the 30-day period who underwent a staged procedure with TEVAR and TAVI. An 84-year-old male who underwent EVAR first and TAVI after 86 days; the 2nd postoperative course was complicated by urinary sepsis causing final exitus. Major adverse events were reported in five patients including cardiac events (n=1), respiratory adverse events (n=3) and cerebrovascular adverse events (n=1).5 Transient spinal cord injury appeared in one patient 48 hours postoperatively who underwent a simultaneous treatment. Magnetic resonance imaging of the thoracic spine revealed no evidence of spinal cord infarction or epidural haematoma. The patient fully recovered with vasopressor therapy.6 The mean length of stay was 12 days (range, 4-21 days).

Late outcomes

The mean follow-up duration was 10 months (range, 1-25 months). During this period, no complications were reported in any of the included studies.

B. Endovascular aortic aneurysm repair and Transcatheter aortic valve implantation

Twenty-two studies2, 5, 7-26, 30 with an overall of 226 patients reported data based on TAVI and EVAR (Table 2). The mean patient age was 79 years (range, 67-91 years). The mean maximum aortic diameter was 55 mm (range, 30-70 mm). Twelve patients underwent a single-stage procedure, whereas five patients were treated using a staged approach.

The Evolut Pro (Medtronic, Minneapolis, MN, USA) was selected in five studies,8, 9, 15, 16, 18, 21, 26, the Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) was used in five studies,9, 10, 14, 17, 20 the Portico (Abbott Laboratories, Abbott Park, IL, USA) in two studies21, 24 and the Lotus (Boston Scientific Corporation, Marlborough, MA, USA) in two studies.12, 22 Main aortic endografts were the Zenith platform (Cook Medical, Bloomington, IN, USA) which was used in seven studies9, 10, 13, 15-17, 22 the Excluder (W. L. Gore & Associates, Flagstaff, AZ, USA) was selected in five studies9, 14, 20, 21, 23 the Endurant aortic device (Medtronic, Minneapolis, MN, USA) in four studies9, 11, 20, 26 the InCraft (Cordis, Miami Lakes, FL, USA) and the Ovation (Endologix, Irvine, CA, USA) devices were selected in two studies.18, 24 In the remaining cases, the type of thoracic endograft was not specified.

Early outcomes

During the early period, no deaths were noted. Type II endoleak was the most common complication after EVAR and was reported in four studies.5, 9, 10, 25 One type III endoleak was reported in one study after use of the Ovation platform originating in the overlap of the limbs and the main body.18 Serial balloon dilatations was performed and the final angiography revealed absence of any type endoleak and exlusion of the aneurysm sac.18 Other additional complications were access related (n=2; pseudoaneurysm and dissection in the puncture site) with endarterectomy of common femoral artery and patchoplasty. Major adverse events were reported in six cases including cardiac events (n=1), respiratory adverse events (n=2) and cerebrovascular adverse events (n=1).5 The mean length of stay was 8 days (range, 5-22 days).

Late outcomes

The mean follow-up duration was 7 months (range, 1-25 months). During this period, a recoil of iliac artery has been detected and was treated successfully putting a new stent graft.5 Additionally one new pseudoaneurysm was detected and was treated in the same study.5 Type II endoleak was detected after six months and was managed conservatively.

DISCUSSION

The coexistence of severe aortic valve stenosis and aortic aneurysmal disease represents a complex clinical scenario that is increasingly encountered in the aging population.43 Advances in minimally invasive therapies have expanded treatment options for patients who are considered high or prohibitive risk for open surgery. In this context, the combination of transcatheter aortic valve implantation (TAVI) and endovascular aortic repair (EVAR or TEVAR) has emerged as a feasible alternative to conventional open approaches, aiming to reduce perioperative morbidity and mortality.43,44

The present review demonstrates that combined transcatheter and endovascular treatment has been applied predominantly in elderly, high-risk patients, with encouraging procedural success and acceptable short- to mid-term outcomes. The reported experience, although limited, suggests that both simultaneous and staged strategies are technically feasible.2,5 However, the staged approach most frequently with TAVI performed prior to aortic repair appears to be favored in the majority of published cases.26 This preference likely reflects concerns regarding the hemodynamic consequences of relieving aortic stenosis, which may increase aortic wall stress and theoretically predispose to aneurysm expansion or rupture if the aneurysm is left untreated.45

From a pathophysiological perspective, the sequences of procedures remains a matter of debate. Performing TAVI first may improve cardiac output and hemodynamic stability, thereby reducing the risk associated with subsequent endovascular aortic repair.26 Conversely, aneurysm exclusion prior to valve intervention may theoretically protect against post-TAVI increases in systolic pressure and wall stress. 26 The available literature does not provide sufficient comparative data to support one strategy over the other, underscoring the importance of individualized decision-making based on aneurysm size, morphology, symptomatology, and overall patient risk profile.41,42

Current clinical guidelines from the American Heart Association (AHA) and American College of Cardiology (ACC) do not provide specific recommendations on the management of patients with concomitant aortic valve stenosis and aortic aneurysmal disease requiring combined transcatheter and endovascular repair.44,45 However, the 2022 ACC/AHA Guidelines for the Diagnosis and Management of Aortic Disease, which addresses thoracic aortic pathology more broadly, underscores the importance of multidisciplinary care and procedural expertise when managing complex aortic conditions, including the use of endovascular techniques such as TEVAR in anatomically suitable patients.44 In addition, established ACC/AHA valvular heart disease guidelines emphasize that TAVI should be performed by experienced multidisciplinary Heart Team programs with comprehensive preprocedural planning to optimize outcomes.46 These guideline principles implicitly support cautious application of combined strategies, but specific evidence-based recommendations for sequencing or integration of TAVI and TEVAR / EVAR in the same patient remain unavailable, reflecting the need for further data.

In contrast to the small case reports and case series included in the present review where no procedural complications were documented, data from larger observational cohorts studies of TEVAR / EVAR and TAVI in similar high-risk populations have reported notable adverse event rates.2,5 Specifically, late complications following thoracic endovascular aortic repair (TEVAR), including endoleaks, and need for secondary interventions, have been observed in up to approximately 38% of patients in broad clinical series, with reinterventions reported in nearly one-quarter of cases.2,5,43 This highlights that while individual case reports may not capture the full spectrum of complications, aggregate experience from larger populations demonstrates important procedural risks that must be considered when planning combined interventions. Likewise, large registries of TAVI have identified vascular access complications, stroke, and conduction disturbances as recognized adverse outcomes, underscoring that procedural safety in real-world cohorts may differ from isolated case descriptions.43

Future research should focus on multicenter registries and collaborative studies to better define patient selection criteria, procedural sequencing, and long-term outcomes. The establishment of standardized reporting frameworks may further enhance comparability across studies. Until higher-level evidence becomes available, the management of patients with concomitant severe aortic stenosis and aortic aneurysmal disease should rely on a multidisciplinary Heart-Vascular Team approach, integrating cardiology, cardiac surgery, and vascular surgery expertise.47

CONCLUSION

In conclusion, combined TAVI and endovascular aortic repair represents a contemporary, minimally invasive treatment option for selected high-risk patients with concomitant aortic valve and aortic pathology. While early outcomes are encouraging, further evidence is required to establish standardized treatment algorithms and long-term safety.

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