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经腔静脉-主动脉入路TAVR1.33.5%Transfemoral
62.6%
手术入路
Transaortic
3.6%
Subclavian
0.3%Transapical2.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。3.非股动脉入路的其他入路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。6.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
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.残余动静脉分流的转归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
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