Abstract
OBJECTIVE: To assess the feasibility and effectiveness of valve-in-valve caval implantation using a balloon-expandable valve after AndraStent prestenting for bioprosthetic dysfunction in challenging venous anatomy. KEY STEPS: Computed tomography showed a 34-mm inferior vena cava (IVC), exceeding available balloon-expandable valve sizes. A 39-mm Andra XXL stent was used for IVC downsizing, enabling successful implantation of a 30-mm balloon-expandable valve, with postprocedural transesophageal echocardiography confirming optimal positioning and no regurgitation. POTENTIAL PITFALLS: Valve-in-valve caval implantation after prior caval valve implantation is technically challenging. Accurate imaging and sizing are critical to avoid malapposition, migration, or caval injury. Landing-zone selection must preserve hepatic venous inflow. Controlled Andra XXL expansion with fluoroscopy and transesophageal echocardiography optimizes alignment, while vigilant anticoagulation and follow-up mitigate thrombosis risk. TAKE-HOME MESSAGES: Comprehensive multimodality imaging is critical to identify prosthetic dysfunction and guide safe reintervention after prior caval valve implantation. Stent-assisted IVC downsizing can enable successful valve-in-valve caval implantation, with durable outcomes dependent on accurate sizing and precise deployment.