经腔静脉主动脉入路TAVR培训课件

1、经腔静脉主动脉入路TAVR33.5%Transfemoral62.6%手术入路Transaortic 3.6%Subclavian 0.3%Transapical2经腔静脉主动脉入路TAVR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经腔静脉主动脉入路TAVR非股动脉入路的其他入路CarotiddirectaortictransapicalIliac-aorticconduitsTranscavalsubclavian/Percut

2、aneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic4经腔静脉主动脉入路TAVR5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，手术获得了成功。6经腔静脉主动脉入路TAVR经腔静脉-主动脉路径TAVRProcedure schematicA:

3、 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.Aortic bleeding decompresses through a hole in IVCinto vasculature7经腔

4、静脉主动脉入路TAVRRecommendation(CA-TAVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelante

5、riortotargetCavallumendiameter23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesRe

6、viewersNHLBIMChenread.2014-xx-xxSTEP #1 Obtain CT-based Treatment PlanLederman, JACC Imaging, 2014Marcus Chen, NHLBI Core Lab8经腔静脉主动脉入路TAVRSTEP #2 Simultaneous Aortic and IVC AngiographyPower inject artery below SMA (10ml for 1 sec)Hand-inject vein simultaneously9经腔静脉主动脉入路TAVRSTEP #3 - Prepare Cross

7、ing System0.014”guidewire0.014” to0.035” wireconvertor0.035”microcatheterBack end of0.014”guidewireElectrosurgerypencilCOAXIAL Confienza amputated tip,inside aPiggyback wire convertor,inside aNavicross braided 0.035microcatheter, to deliverlater Lunderquist(or)2x20mm Advance Micro14 tibial balloon i

8、nside a0.035 CXI support catheterELECTROSURGERYNo short circuitsGround pad withoutinterposed metallic hips &pacemakers50W “cutting” modeAdvance Micro 142.9F ID compatible0.035” CXI support catheter10经腔静脉主动脉入路TAVRAoIVCSTEP #4 Align Guiding Catheter in Orthogonal ViewsIn lateral projection, fine-tuneo

9、rientation away from bowel orcalcium as neededWire tipPiggyback tipDuodenumNavicross tipDifferent patient11经腔静脉主动脉入路TAVRSTEP #6 - Snaring and Advancingasp ic positionAdvance in tandem withtraversal wire & wire convertor13经腔静脉主动脉入路TAVRSTEP #7 - Sheath InsertionHemostasis is universalSide arm up forEd

10、wards eSheathAdvance sheath in one step14经腔静脉主动脉入路TAVRSheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP #8 Select a Closure DeviceCurrent Closure Device Algorithm15经腔静脉主动脉入路TAVRPlace buddy wireInsert deflectable sheathPassively expose aortic discPosition pigt

11、ailWithdraw 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经腔静脉主动脉入路TAV

12、RReview angio beforerelease cable and buddywireIf bleeding Consider balloon aortictamponade Consider endograftClose venous access siteand wait 10 minutesRepeat angiogramSTEP #10 Completion Angiography17经腔静脉主动脉入路TAVRPatterns of Completion AngiographyN=16Complete occlusionN=16Caval-aortic fistula with

13、long tunnel,no extravasationN=42Caval-aortic fistula +“cruciform” extra-aorticcontrastN=5Extravasation(Endograft 7 hrs. later)Type 0Type 1Type 2Type 3MostcommonpatternOf 79 cases18经腔静脉主动脉入路TAVR残余动静脉分流的转归19经腔静脉主动脉入路TAVRTranscaval Access for TAVR IDE RegistryNIH sponsored - site monitoring, DSMB overs

14、ight, CEC adjudication ofprimary and secondary endpoints20 sites, 100 patient, nonrandomized prospective registry; concomitantretrospective registry of all known casesPrimary endpoint: “device success” successful transcaval access andclosure without death related to access or closureEnrollment began

15、 10/201499/100 patients enrolled20经腔静脉主动脉入路TAVRCenterHenry Ford Hospital1Detroit, MITotal79IDE37Angiografia de Occidente2Cali, Colombia15Detroit Medical CenterDetroit, MI3Spectrum HealthGrand Rapids, MI1Emory UniversityAtlanta, GA2516University of UtahSalt Lake City, UT2Oklahoma HeartTulsa, OK118Bri

16、gham and WomensBoston, MA1Columbia UniversityNew York, NY21IDECenterGerman Heart CenterMunich, GETotal3Wake Forest Baptist HealthWinston Salem, NC74Good SamaritanCincinnati, OH3Edward HospitalNaperville, IL54Cleveland Clinic FoundationCleveland, OH3University of VirginiaCharlottesville, VA71York Hos

17、pitalYork, PA33Toledo HospitalToledo, OH31Vanderbilt UniversityNashville, TN53CenterSt. Vincents HospitalIndianapolis, INTotal2IDE2Instituto Dante Pazzanese deCardiologia, Sao Paulo, BR1Terrebone HospitalHouma, LA21Lexington Medical CenterColombia, SC76Washington Hospital CenterWashington, DC11Ochsn

18、er Medical CenterNew Orleans, LA77London Health Sciences CtrLondon, ON1Carilion Medical CenterRoanoke, VA22Evanston HospitalChicago, IL22Total21499Worldwide TranscavalTAVI ExperienceStatus as of 2016Bold: independently performing21经腔静脉主动脉入路TAVRConclusions: Transcaval TAVR Transcaval access enabled T

19、AVR in patients ineligible fortransfemoral access and at high or prohibitive risk oftransthoracic (transapical or transaortic) access Independently-adjudicated bleeding and vascular complicationswere acceptable in this high risk cohort. Compared with lower-risk patients in PARTNER-II, transcavalblee

20、ding was greater than femoral-artery but less thantransthoracic access Transcaval access and closure should be investigated in patientswho otherwise might undergo transthoracic access Purpose-built closure devices are under development that maysimplify the procedure and reduce bleeding22经腔静脉主动脉入路TAVRTranscaval TAVR Feasible, teachable, has now been applied to 200 pts todate