经腔静脉主动脉入路TAVR

经腔静脉-主动脉入路TAVR现在是1页\一共有26页\编辑于星期四33.5%Transfemoral

62.6%

手术入路

Transaortic

3.6%

Subclavian

0.3%Transapical现在是2页\一共有26页\编辑于星期四手术入路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。现在是3页\一共有26页\编辑于星期四非股动脉入路的其他入路Carotid

direct

aortic

transapical

Iliac-aortic

conduitsTranscavalsubclavian/Percutaneous

axillaryNewer-ExtrathoracicHistorical-Intrathoracic现在是4页\一共有26页\编辑于星期四现在是5页\一共有26页\编辑于星期四2013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。现在是6页\一共有26页\编辑于星期四经腔静脉-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现在是7页\一共有26页\编辑于星期四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现在是8页\一共有26页\编辑于星期四STEP#2–SimultaneousAorticandIVCAngiographyPower

inject

artery

below

SMA

(10ml

for

1

sec)Hand-inject

vein

simultaneously现在是9页\一共有26页\编辑于星期四STEP#3-PrepareCrossingSystem0.014”guidewire0.014”

to0.035”wireconvertor0.035”microcatheterBack

endof0.014”guidewireElectrosurge

rypencilCOAXIAL•Confienza

amputated

tip,••insideaPiggybackwireconvertor,inside

aNavicross

braided

0.035microcatheter,to

deliverlaterLunderquist

(or)•2x20mm

Advance

Micro14

tibial

balloon

inside

a

0.035

CXI

support

catheterELECTROSURGERY••No

shortcircuitsGroundpad

withoutinterposed

metallichips&pacemakers•50W“cutting”modeAdvance

Micro

142.9FIDcompatible0.035”CXIsupport

catheter现在是10页\一共有26页\编辑于星期四AoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViews

In

lateral

projection,

fine-tune

orientation

away

from

bowel

or

calcium

as

needed

Wire

tip

Piggyback

tip

DuodenumNavicross

tip

Different

patient现在是11页\一共有26页\编辑于星期四If

it

doesn’t

cross13Like

thisNot

like

thisSTEP#5-CrossingYour

targetmay

betoo

calcific:re-position

or

re-orientYourguidewiretip

may

not

beconductingcurrent:

Disconnected,

charred,short-circuited,etc.Only

attempt

for

about

1sec现在是12页\一共有26页\编辑于星期四STEP#6-SnaringandAdvancingasp

ic

position

Advance

in

tandem

withtraversal

wire

&

wire

convertor现在是13页\一共有26页\编辑于星期四STEP#7-SheathInsertionHemostasis

is

universalSide

arm

upforEdwardseSheathAdvance

sheathin

one

step现在是14页\一共有26页\编辑于星期四Sheath>18FrID<=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength>7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrent

Closure

Device

Algorithm现在是15页\一共有26页\编辑于星期四Place

buddy

wireInsertdeflectablesheathPassively

expose

aorticdiscPosition

pigtailWithdraw

anddeflectsheath

tocrossingpointWithdrawTAVIsheath

intoIVCAdvancepigtailcephalad&

testRetractdisc

onto

R

aorticwallStraightenAgilisduring

withdrawalthrough

tract

into

cavaPull

Amplatzercable

to

reachcava,

then

push

cable

tore-formvenous

sideSTEP#9-Closure现在是16页\一共有26页\编辑于星期四Reviewangiobeforerelease

cable

and

buddywireIf

bleeding

–Considerballoon

aortic

tamponade

–

Consider

endograftClose

venous

access

siteandwait10minutesRepeat

angiogramSTEP#10–CompletionAngiography现在是17页\一共有26页\编辑于星期四Patterns

of

Completion

Angiography

N=16Completeocclusion

N=16Caval-aorticfistulawith

longtunnel,

no

extravasation

N=42

Caval-aortic

fistula+“cruciform”extra-aortic

contrast

N=5

Extravasation(Endograft

7hrs.

later)Type

0Type

1Type

2Type

3

Mostcommon

patternOf

79

cases现在是18页\一共有26页\编辑于星期四残余动静脉分流的转归现在是19页\一共有26页\编辑于星期四Transcaval

Access

for

TAVR

IDE

Registry

NIH

sponsored

-

site

monitoring,

DSMB

oversight,CEC

adjudication

ofprimary

and

secondaryendpoints

20

sites,

100

patient,

nonrandomized

prospectiveregistry;concomitantretrospectiveregistryofall

knowncases

Primary

endpoint:

“device

success”successful

transcaval

access

andclosure

withoutdeath

relatedto

access

orclosure

Enrollmentbegan

10/2014

99/100

patients

enrolled现在是20页\一共有26页\编辑于星期四CenterHenry

Ford

Hospital1Detroit,

MITotal

79IDE

37Angiografia

de

Occidente2Cali,

Colombia15Detroit

MedicalCenterDetroit,MI3Spectrum

HealthGrandRapids,MI1Emory

UniversityAtlanta,

GA2516UniversityofUtahSaltLake

City,UT2Oklahoma

HeartTulsa,

OK118Brighamand

Women’sBoston,

MA1ColumbiaUniversityNewYork,

NY21IDECenterGerman

Heart

CenterMunich,

GETotal

3Wake

Forest

Baptist

HealthWinston

Salem,

NC74Good

SamaritanCincinnati,

OH3Edward

HospitalNaperville,

IL54ClevelandClinicFoundationCleveland,

OH3University

of

VirginiaCharlottesville,

VA71YorkHospitalYork,PA33ToledoHospitalToledo,OH31Vanderbilt

UniversityNashville,

TN53CenterSt.Vincent’sHospitalIndianapolis,INTotal

2IDE

2Instituto

DantePazzanese

deCardiologia,

SaoPaulo,

BR1Terrebone

HospitalHouma,

LA21Lexington

Medical

CenterColombia,

SC76Washington

Hospital

CenterWashington,

DC11Ochsner

Medical

CenterNew

Orleans,

LA77LondonHealthSciencesCtrLondon,ON1Carilion

Medical

CenterRoanoke,VA22Evanston

HospitalChicago,

IL22Total21499Worldwide

Transcaval

TAVI

Experience

Status

as

of

2016Bold:independently

performing现在是21页\一共有26页\编辑于星期四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现在是22页\一共有26页\编辑于星期四Transcaval

TAVR

Feasible,

teachable,has

nowbeen

applie