經(jīng)腔靜脈主動(dòng)脈入路TAVR課件

經(jīng)腔靜脈-主動(dòng)脈入路TAVR1.33.5%Transfemoral

62.6%

手術(shù)入路

Transaortic

3.6%

Subclavian

0.3%Transapical2.手術(shù)入路1、股動(dòng)脈入路常常需要18F-22F鞘管，術(shù)后易出現(xiàn)血管并發(fā)癥，且髂動(dòng)脈嚴(yán)重鈣化迂曲、血管直徑過小或者合并外周動(dòng)脈疾病者存在禁忌。2、包括經(jīng)心尖在內(nèi)的經(jīng)胸腔入路，術(shù)后恢復(fù)慢，且伴隨更多的術(shù)后并發(fā)癥。3.非股動(dòng)脈入路的其他入路Carotid

direct

aortic

transapical

Iliac-aortic

conduitsTranscavalsubclavian/Percutaneous

axillaryNewer-ExtrathoracicHistorical-Intrathoracic4.5.2013年7月3日，在美國底特律HenryFord醫(yī)院，Dr.Lederman和Dr.Greenbaum以及他們的同事們，采用該術(shù)式為一位80歲女性患者成功進(jìn)行了TAVR。術(shù)前，其他介入路徑，如經(jīng)股動(dòng)脈、經(jīng)心尖、經(jīng)鎖骨下等在這位患者身上均嘗試失敗，因此手術(shù)團(tuán)隊(duì)決定實(shí)施首例人類腔靜脈-主動(dòng)脈路徑TAVR手術(shù)，手術(shù)獲得了成功。6.經(jīng)腔靜脈-主動(dòng)脈路徑TAVR

Procedure

schematicA:

Cross

from

IVC

through

calcium-freewindow

into

prepositioned

aortic

snareB:

Exchange

for

rigid

guidewireC:

Deliver

sheath

and

TAVRD:

Close

with

nitinol

occluder

Proposed

physiologyRetroperitoneal

space

pressure

is

higher

than

vein.Aortic

bleeding

decompresses

through

a

hole

in

IVCinto

vasculature7.Recommendation(CA-TAVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxSTEP

#1

–Obtain

CT-based

Treatment

PlanLederman,

JACC

Imaging,

2014

Marcus

Chen,

NHLBI

Core

Lab8.STEP#2–SimultaneousAorticandIVCAngiographyPower

inject

artery

below

SMA

(10ml

for

1

sec)Hand-inject

vein

simultaneously9.STEP#3-PrepareCrossingSystem0.014”guidewire0.014”

to0.035”

wireconvertor0.035”microcatheterBack

end

of0.014”guidewireElectrosurge

rypencilCOAXIAL?

Confienza

amputated

tip,??inside

aPiggyback

wire

convertor,inside

aNavicross

braided

0.035microcatheter,

to

deliverlater

Lunderquist

(or)?2x20mm

Advance

Micro14

tibial

balloon

inside

a

0.035

CXI

support

catheterELECTROSURGERY??No

short

circuitsGround

pad

withoutinterposed

metallic

hips

&pacemakers?50W

“cutting”

modeAdvance

Micro

142.9F

ID

compatible0.035”

CXI

support

catheter10.AoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViews

In

lateral

projection,

fine-tune

orientation

away

from

bowel

or

calcium

as

needed

Wire

tip

Piggyback

tip

DuodenumNavicross

tip

Different

patient11.If

it

doesn’t

cross13Like

thisNot

like

thisSTEP#5-Crossing

Your

target

may

be

too

calcific:

re-position

or

re-orientYour

guidewire

tip

may

not

be

conducting

current:

Disconnected,

charred,

short-circuited,

etc.Only

attempt

for

about

1sec12.STEP#6-SnaringandAdvancingasp

ic

position

Advance

in

tandem

withtraversal

wire

&

wire

convertor13.STEP#7-SheathInsertionHemostasis

is

universalSide

arm

up

forEdwards

eSheathAdvance

sheath

in

one

step14.Sheath>18FrID<=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength>7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrent

Closure

Device

Algorithm15.

Place

buddy

wireInsert

deflectable

sheathPassively

expose

aortic

discPosition

pigtailWithdraw

and

deflect

sheath

tocrossing

pointWithdraw

TAVI

sheath

into

IVCAdvance

pigtail

cephalad

&

testRetract

disc

onto

R

aortic

wallStraighten

Agilis

during

withdrawalthrough

tract

into

cavaPull

Amplatzer

cable

to

reachcava,

then

push

cable

to

re-formvenous

sideSTEP#9-Closure16.

Review

angio

beforerelease

cable

and

buddywireIf

bleeding

–

Consider

balloon

aortic

tamponade

–

Consider

endograftClose

venous

access

siteand

wait

10

minutesRepeat

angiogramSTEP#10–CompletionAngiography17.Patterns

of

Completion

Angiography

N=16Complete

occlusion

N=16Caval-aortic

fistula

with

long

tunnel,

no

extravasation

N=42

Caval-aortic

fistula

+“cruciform”

extra-aortic

contrast

N=5

Extravasation(Endograft

7

hrs.

later)Type

0Type

1Type

2Type

3

Mostcommon

patternOf

79

cases18.殘余動(dòng)靜脈分流的轉(zhuǎn)歸19.Transcaval

Access

for

TAVR

IDE

Registry

NIH

sponsored

-

site

monitoring,

DSMB

oversight,

CEC

adjudication

ofprimary

and

secondary

endpoints

20

sites,

100

patient,

nonrandomized

prospective

registry;

concomitantretrospective

registry

of

all

known

cases

Primary

endpoint:

“device

success”

successful

transcaval

access

andclosure

without

death

related

to

access

or

closure

Enrollment

began

10/2014

99/100

patients

enrolled20.21.CenterHenry

Ford

Hospital1Detroit,

MITotal

79IDE

37Angiografia

de

Occidente2Cali,

Colombia15Detroit

Medical

CenterDetroit,

MI3Spectrum

HealthGrand

Rapids,

MI1Emory

UniversityAtlanta,

GA2516University

of

UtahSalt

Lake

City,

UT2Oklahoma

HeartTulsa,

OK118Brigham

and

Women’sBoston,

MA1Columbia

UniversityNew

York,

NY21IDECenterGerman

Heart

CenterMunich,

GETotal

3Wake

Forest

Baptist

HealthWinston

Salem,

NC74Good

SamaritanCincinnati,

OH3Edward

HospitalNaperville,

IL54Cleveland

Clinic

FoundationCleveland,

OH3University

of

VirginiaCharlottesville,

VA71York

HospitalYork,

PA33Toledo

HospitalToledo,

OH31Vanderbilt

UniversityNashville,

TN53CenterSt.

Vincent’s

HospitalIndianapolis,

INTotal

2IDE

2Instituto

Dante

Pazzanese

deCardiologia,

Sao

Paulo,

BR1Terrebone

HospitalHouma,

LA21Lexington

Medical

CenterColombia,

SC76Washington

Hospital

CenterWashington,

DC11Ochsner

Medical

CenterNew

Orleans,

LA77London

Health

Sciences

CtrLondon,

ON1Carilion

Medical

CenterRoanoke,

VA22Evanston

HospitalChicago,

IL22Total21499Worldwide

Transcaval

TAVI

Experience

Status

as

of

2016Bold:

independently

performing22.Conclusions:TranscavalTAVR?Transcaval

access

enabled

TAVR

in

patients

ineligible

for

transfemoral

access

and

at

high

or

prohibitive

risk

of

transthoracic

(transapical

or

transaortic)

access?Independently-adjudicated

bleeding

and

vascular

complications

were

acceptable

in

this

high

risk

cohort.

–Compared

with

lower-risk

patients

in

PARTNER-II,

transcaval

bleeding

was

greater

than

femoral-artery

but

less

than

transthoracic

access?Transcaval

access

and

closure

should

be

investigated

in

patients

who

otherwise

might

undergo

transthoracic

access?Purpose-built

closure

devices

are

under

development

that

may

simplify

the

procedure

and

reduce

bleeding23.Transcaval

TAVR

Feasible,

teachable,

has

now

been

applied

to