A 69-year-old woman presented with a history of diabetes, hypertension, prior stroke, and renal impairment. She had multiple allergies, including intolerance to blood transfusions and several medications.
Progressive breathlessness, chest pain, and repeated black-out episodes. Investigations confirmed severe aortic stenosis.
Standard transfemoral access was ruled out due to a right femoral stent and a vascular graft on the left side. Both subclavian routes were unsuitable (left subclavian blocked with pacemaker; right subclavian had an anomalous course). With all four conventional access sites unavailable, the team considered the trans-carotid route.
The left carotid artery was chosen for access after confirming adequate collateral blood flow through the Circle of Willis on CT brain angiography to ensure cerebral safety.
A 23 mm ACURATE neo2™ (AN2) valve was selected. Predilation was performed with an 18 mm non-compliant balloon. The valve was deployed successfully, achieving a single-digit gradient and no paravalvular leak. Post-dilation was not required. The iSleeve introducer sheath and AN2 delivery system provided excellent stability throughout the procedure without additional manoeuvring.
The patient recovered well, with significant improvement in daily activity levels. She was discharged in a stable and improved condition.
This is the first successful AN2 implantation via the trans-carotid route in the Asia-Pacific region, demonstrating safety and feasibility of this alternative approach when conventional access routes are not available.