经腔静脉-主动脉入路TAVR课件

经腔静脉-主动脉入路TAVR,1,-主动脉入路TAVR,经腔静脉-主动脉入路TAVR,2,33.5%,Transfemoral62.6%,手术入路Transaortic3.6%Subclavian0.3%Transapical,经腔静脉-主动脉入路TAVR,3,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。,经腔静脉-主动脉入路TAVR,4,非股动脉入路的其他入路,Carotiddirect,aortictransapicalIliac-aorticconduitsTranscaval,subclavian/Percutaneousaxillary,Newer-Extrathoracic,Historical-Intrathoracic,经腔静脉-主动脉入路TAVR,5,经腔静脉-主动脉入路TAVR,6,2013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。,经腔静脉-主动脉入路TAVR,7,经腔静脉-主动脉路径TAVR,ProcedureschematicA:CrossfromIVCthroughcalcium-freewindowintoprepositionedaorticsnareB:ExchangeforrigidguidewireC:DeliversheathandTAVRD:Closewithnitinoloccluder,ProposedphysiologyRetroperitonealspacepressureishigherthanvein.AorticbleedingdecompressesthroughaholeinIVCintovasculature,经腔静脉-主动脉入路TAVR,8,STEP#1ObtainCT-basedTreatmentPlan,Lederman,JACCImaging,2014MarcusChen,NHLBICoreLab,经腔静脉-主动脉入路TAVR,9,STEP#2SimultaneousAorticandIVCAngiography,PowerinjectarterybelowSMA(10mlfor1sec)Hand-injectveinsimultaneously,经腔静脉-主动脉入路TAVR,10,STEP#3-PrepareCrossingSystem,0.014”guidewire0.014”to0.035”wireconvertor,0.035”microcatheter,Backendof0.014”guidewire,Electrosurge,rypencil,COAXIALConfienzaamputatedtip,insideaPiggybackwireconvertor,insideaNavicrossbraided0.035microcatheter,todeliverlaterLunderquist(or),2x20mmAdvanceMicro14tibialballooninsidea,0.035CXIsupportcatheterELECTROSURGERY,NoshortcircuitsGroundpadwithoutinterposedmetallichipsconcomitantretrospectiveregistryofallknowncasesPrimaryendpoint:“devicesuccess”successfultranscavalaccessandclosurewithoutdeathrelatedtoaccessorclosureEnrollmentbegan10/201499/100patientsenrolled,经腔静脉-主动脉入路TAVR,21,CenterHenryFordHospital1,Detroit,MI,Total79,IDE37,AngiografiadeOccidente2,Cali,Colombia,15,DetroitMedicalCenter,Detroit,MI,3,SpectrumHealth,GrandRapids,MI,1,EmoryUniversity,Atlanta,GA,25,16,UniversityofUtah,SaltLakeCity,UT,2,OklahomaHeart,Tulsa,OK,11,8,BrighamandWomens,Boston,MA,1,ColumbiaUniversity,NewYork,NY,2,1,IDE,CenterGermanHeartCenter,Munich,GE,Total3,WakeForestBaptistHealth,WinstonSalem,NC,7,4,GoodSamaritan,Cincinnati,OH,3,EdwardHospital,Naperville,IL,5,4,ClevelandClinicFoundation,Cleveland,OH,3,UniversityofVirginia,Charlottesville,VA,7,1,YorkHospital,York,PA,3,3,ToledoHospital,Toledo,OH,3,1,VanderbiltUniversity,Nashville,TN,5,3,CenterSt.VincentsHospital,Indianapolis,IN,Total2,IDE2,InstitutoDantePazzanesede,Cardiologia,SaoPaulo,BR,1,TerreboneHospital,Houma,LA,2,1,LexingtonMedicalCenter,Colombia,SC,7,6,WashingtonHospitalCenter,Washington,DC,1,1,OchsnerMedicalCenter,NewOrleans,LA,7,7,LondonHealthSciencesCtr,London,ON,1,CarilionMedicalCenter,Roanoke,VA,2,2,EvanstonHospital,Chicago,IL,2,2,Total,214,99,WorldwideTranscavalTAVIExperienceStatusasof2016,Bold:independentlyperforming,经腔静脉-主动脉入路TAVR,22,Conclusions:TranscavalTAVR,TranscavalaccessenabledTAVRinpatientsineligiblefortransfemoralaccessandathighorprohibitiveriskoftransthoracic(transapicalortransaortic)accessIndependently-adjudicatedbleedingandvascularcomplicationswereacceptableinthishighriskcohort.Comparedwithlower-riskpatientsinPARTNER-II,transcavalbleedingwasgreaterthanfemoral-arterybutlessthantransthoracicaccessTranscavalaccessandclosureshouldbeinvestigatedinpatientswhootherwisemightundergotransthoracicaccessPurpose-builtclosuredevicesareunderdevelopmentthatmaysimplifytheprocedureandreducebleeding,经腔静脉-主动脉入路TAVR,23,TranscavalTAVR,Feasible,teachable,hasnowbeenappliedto200ptsto,datebutshouldbeplannedcarefully;werecommendproctoring,Bleedingandtransfusionarenowmuchlesscommonand,similartotransfemoralTAVRasislengthofstay,NHLBIsponsoredUSmulticenterIDEusingAmplatzer,devicesis99%completed,Dedicatedclosuredevicestoachieveimmediate,hemostasisareindevelopment,经腔静脉-主动脉入路TAVR,24,Caval-AorticAccessFutureDirectionsCaval-aorticaccesshasnowbeenutilizedforTEVAR,tempora