经腔静脉主动脉入路TAVR

经腔静脉-主动脉入路TAVR当前第1页\共有26页\编于星期五\11点33.5%Transfemoral

62.6%

手术入路

Transaortic

3.6%

Subclavian

0.3%Transapical当前第2页\共有26页\编于星期五\11点手术入路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。当前第3页\共有26页\编于星期五\11点非股动脉入路的其他入路Carotid

direct

aortic

transapical

Iliac-aortic

conduitsTranscavalsubclavian/Percutaneous

axillaryNewer-ExtrathoracicHistorical-Intrathoracic当前第4页\共有26页\编于星期五\11点当前第5页\共有26页\编于星期五\11点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。当前第6页\共有26页\编于星期五\11点经腔静脉-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当前第7页\共有26页\编于星期五\11点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当前第8页\共有26页\编于星期五\11点STEP#2–SimultaneousAorticandIVCAngiographyPower

inject

artery

below

SMA

(10ml

for

1

sec)Hand-inject

vein

simultaneously当前第9页\共有26页\编于星期五\11点STEP#3-PrepareCrossingSystem0.014”guidewire0.014”

to0.035”

wireconvertor0.035”microcatheterBackendof0.014”guidewireElectrosurge

rypencilCOAXIAL•

Confienza

amputated

tip,••insideaPiggyback

wireconvertor,inside

aNavicross

braided

0.035microcatheter,

todeliverlater

Lunderquist

(or)•2x20mm

Advance

Micro14

tibial

balloon

inside

a

0.035

CXI

support

catheterELECTROSURGERY••No

short

circuitsGround

padwithoutinterposed

metallic

hips

&pacemakers•50W

“cutting”

modeAdvance

Micro

142.9F

IDcompatible0.035”CXIsupportcatheter当前第10页\共有26页\编于星期五\11点AoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViews

In

lateral

projection,

fine-tune

orientation

away

from

bowel

or

calcium

as

needed

Wire

tip

Piggyback

tip

DuodenumNavicross

tip

Different

patient当前第11页\共有26页\编于星期五\11点If

it

doesn’t

cross13Like

thisNot

like

thisSTEP#5-CrossingYour

targetmay

betoo

calcific:re-positionor

re-orientYourguidewiretip

maynotbe

conducting

current:

Disconnected,

charred,short-circuited,

etc.Only

attempt

for

about

1sec当前第12页\共有26页\编于星期五\11点STEP#6-SnaringandAdvancingasp

ic

position

Advance

in

tandem

withtraversal

wire

&

wire

convertor当前第13页\共有26页\编于星期五\11点STEP#7-SheathInsertionHemostasis

is

universalSidearmupforEdwards

eSheathAdvance

sheathin

one

step当前第14页\共有26页\编于星期五\11点Sheath>18FrID<=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength>7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrent

Closure

Device

Algorithm当前第15页\共有26页\编于星期五\11点Place

buddywireInsertdeflectablesheathPassivelyexpose

aortic

discPosition

pigtailWithdraw

anddeflectsheathtocrossingpointWithdrawTAVIsheath

intoIVCAdvancepigtail

cephalad&

testRetract

discontoRaortic

wallStraightenAgilisduringwithdrawalthrough

tract

into

cavaPull

Amplatzer

cable

toreachcava,

thenpush

cable

to

re-formvenoussideSTEP#9-Closure当前第16页\共有26页\编于星期五\11点Review

angiobeforereleasecableandbuddywireIfbleeding

–Considerballoonaortic

tamponade

–

Consider

endograftClose

venous

access

siteandwait10

minutesRepeat

angiogramSTEP#10–CompletionAngiography当前第17页\共有26页\编于星期五\11点Patterns

of

Completion

Angiography

N=16Completeocclusion

N=16Caval-aortic

fistula

with

longtunnel,

no

extravasation

N=42

Caval-aorticfistula+“cruciform”

extra-aortic

contrast

N=5

Extravasation(Endograft7

hrs.later)Type

0Type

1Type

2Type

3

Mostcommon

patternOf

79

cases当前第18页\共有26页\编于星期五\11点残余动静脉分流的转归当前第19页\共有26页\编于星期五\11点Transcaval

Access

for

TAVR

IDE

Registry

NIHsponsored-sitemonitoring,

DSMBoversight,

CECadjudication

ofprimaryand

secondary

endpoints

20

sites,100

patient,nonrandomized

prospectiveregistry;

concomitantretrospectiveregistry

of

allknowncases

Primaryendpoint:

“device

success”successfultranscaval

access

andclosurewithoutdeathrelated

to

accessor

closure

Enrollment

began

10/2014

99/100patients

enrolled当前第20页\共有26页\编于星期五\11点CenterHenry

Ford

Hospital1Detroit,

MITotal

79IDE

37Angiografia

de

Occidente2Cali,

Colombia15Detroit

Medical

CenterDetroit,MI3Spectrum

HealthGrand

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,

IL54Cleveland

ClinicFoundationCleveland,

OH3University

of

VirginiaCharlottesville,

VA71YorkHospitalYork,

PA33Toledo

HospitalToledo,

OH31Vanderbilt

UniversityNashville,

TN53CenterSt.

Vincent’sHospitalIndianapolis,

INTotal

2IDE

2Instituto

Dante

Pazzanese

deCardiologia,SaoPaulo,

BR1Terrebone

HospitalHouma,LA21Lexington

Medical

CenterColombia,

SC76Washington

HospitalCenterWashington,

DC11Ochsner

Medical

CenterNew

Orleans,

LA77London

Health

Sciences

CtrLondon,

ON1CarilionMedicalCenterRoanoke,

VA22Evanston

HospitalChicago,

IL22Total21499Worldwide

Transcaval

TAVI

Experience

Status

as

of

2016Bold:

independently

performing当前第21页\共有26页\编于星期五\11点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当前第22页\共有26页\编于星期五\11点Transcaval

TAVRFeasible,

teachable,

hasnow

been

applied