经腔静脉主动脉入路TAVR

经腔静脉-主动脉入路TAVR第一页，共二十六页。33.5%Transfemoral

62.6%

手术入路

Transaortic

3.6%

Subclavian

0.3%Transapical第二页，共二十六页。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。第三页，共二十六页。非股动脉入路的其他入路Carotid

direct

aortic

transapical

Iliac-aortic

conduitsTranscavalsubclavian/Percutaneous

axillaryNewer-ExtrathoracicHistorical-Intrathoracic第四页，共二十六页。第五页，共二十六页。2013年7月3日，在美国底特律HenryFord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，手术获得了成功。第六页，共二十六页。经腔静脉-主动脉路径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

vasculature第七页，共二十六页。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

Lab第八页，共二十六页。STEP#2–SimultaneousAorticandIVCAngiographyPower

inject

artery

below

SMA

(10ml

for

1

sec)Hand-inject

vein

simultaneously第九页，共二十六页。STEP#3-PrepareCrossingSystem0.014”guidewire0.014”to0.035”wireconvertor0.035”microcatheterBack

endof0.014”guidewireElectrosurge

rypencilCOAXIAL•

Confienza

amputatedtip,••inside

aPiggybackwireconvertor,insideaNavicross

braided

0.035microcatheter,

todeliverlater

Lunderquist

(or)•2x20mm

Advance

Micro14

tibial

balloon

inside

a

0.035

CXI

support

catheterELECTROSURGERY••No

short

circuitsGroundpadwithoutinterposed

metallic

hips&pacemakers•50W“cutting”

modeAdvance

Micro

142.9F

ID

compatible0.035”

CXI

support

catheter第十页，共二十六页。AoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViews

In

lateral

projection,

fine-tune

orientation

away

from

bowel

or

calcium

as

needed

Wire

tip

Piggyback

tip

DuodenumNavicross

tip

Different

patient第十一页，共二十六页。If

it

doesn’t

cross13Like

thisNot

like

thisSTEP#5-CrossingYour

targetmay

be

too

calcific:re-positionorre-orientYour

guidewire

tip

may

not

be

conductingcurrent:

Disconnected,

charred,

short-circuited,

etc.Only

attempt

for

about

1sec第十二页，共二十六页。STEP#6-SnaringandAdvancingasp

ic

position

Advance

in

tandem

withtraversal

wire

&

wire

convertor第十三页，共二十六页。STEP#7-SheathInsertionHemostasis

is

universalSidearmupforEdwards

eSheathAdvancesheath

inonestep第十四页，共二十六页。Sheath>18FrID<=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength>7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrent

Closure

Device

Algorithm第十五页，共二十六页。Place

buddywireInsert

deflectablesheathPassivelyexpose

aorticdiscPosition

pigtailWithdraw

and

deflect

sheath

tocrossingpointWithdrawTAVIsheathintoIVCAdvancepigtail

cephalad

&

testRetract

disconto

R

aortic

wallStraighten

Agilis

during

withdrawalthrough

tractintocavaPullAmplatzercable

toreachcava,

thenpush

cable

to

re-formvenous

sideSTEP#9-Closure第十六页，共二十六页。Reviewangiobeforereleasecable

and

buddywireIfbleeding

–Considerballoonaortic

tamponade

–

ConsiderendograftClose

venousaccesssiteand

wait10

minutesRepeat

angiogramSTEP#10–CompletionAngiography第十七页，共二十六页。Patterns

of

Completion

Angiography

N=16Completeocclusion

N=16Caval-aorticfistulawith

long

tunnel,

noextravasation

N=42

Caval-aorticfistula

+“cruciform”

extra-aortic

contrast

N=5

Extravasation(Endograft7hrs.

later)Type

0Type

1Type

2Type

3

Mostcommon

patternOf

79

cases第十八页，共二十六页。残余动静脉分流的转归第十九页，共二十六页。Transcaval

Access

for

TAVR

IDE

Registry

NIH

sponsored

-sitemonitoring,

DSMBoversight,

CEC

adjudication

ofprimary

and

secondary

endpoints

20

sites,100patient,

nonrandomizedprospective

registry;concomitantretrospectiveregistry

ofallknowncases

Primary

endpoint:“device

success”successfultranscavalaccess

andclosurewithoutdeathrelatedto

accessor

closure

Enrollmentbegan

10/2014

99/100

patients

enrolled第二十页，共二十六页。CenterHenry

Ford

Hospital1Detroit,

MITotal

79IDE

37Angiografia

de

Occidente2Cali,

Colombia15Detroit

Medical

CenterDetroit,

MI3SpectrumHealthGrand

Rapids,MI1Emory

UniversityAtlanta,

GA2516Universityof

UtahSalt

Lake

City,UT2Oklahoma

HeartTulsa,

OK118Brigham

and

Women’sBoston,MA1Columbia

UniversityNewYork,NY21IDECenterGerman

Heart

CenterMunich,

GETotal

3Wake

Forest

Baptist

HealthWinston

Salem,

NC74Good

SamaritanCincinnati,

OH3Edward

HospitalNaperville,

IL54ClevelandClinicFoundationCleveland,OH3University

of

VirginiaCharlottesville,

VA71YorkHospitalYork,

PA33ToledoHospitalToledo,

OH31Vanderbilt

UniversityNashville,

TN53CenterSt.Vincent’s

HospitalIndianapolis,

INTotal

2IDE

2Instituto

Dante

PazzanesedeCardiologia,

Sao

Paulo,BR1TerreboneHospitalHouma,

LA21Lexington

Medical

CenterColombia,

SC76WashingtonHospitalCenterWashington,DC11Ochsner

Medical

CenterNew

Orleans,

LA77LondonHealthSciencesCtrLondon,

ON1CarilionMedicalCenterRoanoke,

VA22Evanston

HospitalChicago,IL22Total21499Worldwide

Transcaval

TAVI

Experience

Status

as

of

2016Bold:

independentlyperforming第二十一页，共二十六页。Conclusions:

Transcaval

TAVR•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

bleeding第二十二页，共二十六页。Transcaval

TAVRFeasible,teachable,hasnow

beenapplied