1410 - Leg Pain After TAVR: Not Always Vascular

We present a 76-year-old female with a history of heart failure, hypertension, diabetes, stage 4 chronic kidney disease, cirrhosis post liver transplant, and severe aortic stenosis after transcatheter aortic valve replacement (TAVR). She reported sharp, aching pain radiating from the right hip through the thigh and knee beginning after right transfemoral TAVR. Exam revealed tenderness over the lumbar paraspinals, gluteal muscles, and greater trochanter, limited lumbar motion, and weakness in hip flexion, raising concern for femoral nerve injury, a possible complication of femoral-access TAVR. X-rays showed mild degenerative hip changes and intact knee arthroplasty. A right greater trochanteric bursa injection under ultrasound guidance gave no relief. Magnetic resonance imaging (MRI) showed multilevel lumbar stenosis at L3–4 and L4–5, while hip MRI revealed iliopsoas tendinopathy. Two right L3–4 transforaminal epidural steroid injections (TFESIs) gave pain relief, followed by contralateral injections for new left-sided pain. 

Discussions: Groin complications such as hematoma, pseudoaneurysm, and vascular injury are well-described after femoral artery access for TAVR, but persistent leg pain is less common. The patient’s temporal presentation and hip flexion weakness suggested femoral nerve injury. TFESI may have been therapeutic by targeting the nerve roots proximal to the femoral nerve, offering improvement in pain. Concurrently, imaging and limited response to bursal injection supported lumbar stenosis as a contributing etiology.

Conclusions:

This case highlights the need for a broad differential in patients with leg pain following TAVR. Beyond vascular causes, femoral nerve injury should be considered in those with hip flexion weakness. Importantly, TFESI can provide therapeutic benefit not only in lumbar radiculopathy, but also in femoral nerve injury post-TAVR.