经腔静脉-主动脉入路TAVR课件

1、经腔静脉-主动脉入路TAVR经腔静脉-主动脉入路TAVR33.5%Transfemoral62.6%手术入路Transaortic 3.6%Subclavian 0.3%Transapical33.5%Transfemoral手术入路手术入路1、股动脉入路常常需要18F-22F鞘管，术后易出现血管并发症，且髂动脉严重钙化迂曲、血管直径过小或者合并外周动脉疾病者存在禁忌。2、包括经心尖在内的经胸腔入路，术后恢复慢，且伴随更多的术后并发症。手术入路1、股动脉入路常常需要18F-22F鞘管，术后易出现非股动脉入路的其他入路CarotiddirectaortictransapicalIliac-aor

2、ticconduitsTranscavalsubclavian/Percutaneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic非股动脉入路的其他入路Carotidaorticsubcl经腔静脉-主动脉入路TAVR2013年7月3日，在美国底特律Henry Ford医院，Dr. Lederman和Dr. Greenbaum以及他们的同事们，采用该术式为一位80岁女性患者成功进行了TAVR。术前，其他介入路径，如经股动脉、经心尖、经锁骨下等在这位患者身上均尝试失败，因此手术团队决定实施首例人类腔静脉-主动脉路径TAVR手术，手术获得

3、了成功。2013年7月3日，在美国底特律Henry Ford医院，D经腔静脉-主动脉路径TAVRProcedure schematicA: Cross from IVC through calcium-freewindow into prepositioned aortic snareB: Exchange for rigid guidewireC: Deliver sheath and TAVRD: Close with nitinol occluderProposed physiologyRetroperitoneal space pressure is higher than vein.

4、Aortic bleeding decompresses through a hole in IVCinto vasculature经腔静脉-主动脉路径TAVRProcedure schemRecommendation(CA-TAVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm

5、(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotarget

6、centerlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxSTEP #1 Obtain CT-based Treatment PlanLederman, JACC Imaging, 2014Marcus Chen, NHLBI Core LabRecommendation(CA-TAVReligibilSTEP #2 Simultaneous Aortic and IVC AngiographyPower inject a

7、rtery below SMA (10ml for 1 sec)Hand-inject vein simultaneouslySTEP #2 Power inject artery STEP #3 - Prepare Crossing System0.014”guidewire0.014” to0.035” wireconvertor0.035”microcatheterBack end of0.014”guidewireElectrosurgerypencilCOAXIAL Confienza amputated tip,inside aPiggyback wire convertor,in

8、side aNavicross braided 0.035microcatheter, to deliverlater Lunderquist(or)2x20mm Advance Micro14 tibial balloon inside a0.035 CXI support catheterELECTROSURGERYNo short circuitsGround pad withoutinterposed metallic hips &pacemakers50W “cutting” modeAdvance Micro 142.9F ID compatible0.035” CXI suppo

9、rt catheterSTEP #3 - Prepare Crossing SysAoIVCSTEP #4 Align Guiding Catheter in Orthogonal ViewsIn lateral projection, fine-tuneorientation away from bowel orcalcium as neededWire tipPiggyback tipDuodenumNavicross tipDifferent patientAoIVCSTEP #4 Navicross tipIf it doesnt cross13Like thisNot like th

10、isSTEP #5 - CrossingYour 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 1secIf it doesnt cross13Like thisSTEP #6 - Snaring and Advancingasp ic positionAdvance in tandem withtraver

11、sal wire & wire convertorSTEP #6 - Snaring and AdvancinSTEP #7 - Sheath InsertionHemostasis is universalSide arm up forEdwards eSheathAdvance sheath in one stepSTEP #7 - Sheath InsertionHemoSheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP #8 Select a Closure

12、 DeviceCurrent Closure Device AlgorithmSheath18FrID200 pts todate but should be planned carefully; we recommendproctoring Bleeding and transfusion are now much less common andsimilar to transfemoral TAVR as is length of stay NHLBI sponsored US multicenter IDE using Amplatzerdevices is 99% completed Dedicated closure devices to achieve immediatehemostasis are in developmentTranscaval TAVR Feasible, tCaval-Aortic Access Future Directions Caval-aortic access has now been utilized for TEVAR,temporary LV assist device placement for cardiogenicshock an