经腔静脉主动脉入路TAVR

经腔静脉-主动脉入路TAVR本文档共26页；当前第1页；编辑于星期二\18点43分33.5%Transfemoral

62.6%

手术入路

Transaortic

3.6%

Subclavian

0.3%Transapical本文档共26页；当前第2页；编辑于星期二\18点43分手术入路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。本文档共26页；当前第3页；编辑于星期二\18点43分非股动脉入路的其他入路Carotid

direct

aortic

transapical

Iliac-aortic

conduitsTranscavalsubclavian/Percutaneous

axillaryNewer-ExtrathoracicHistorical-Intrathoracic本文档共26页；当前第4页；编辑于星期二\18点43分本文档共26页；当前第5页；编辑于星期二\18点43分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。本文档共26页；当前第6页；编辑于星期二\18点43分经腔静脉-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本文档共26页；当前第7页；编辑于星期二\18点43分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本文档共26页；当前第8页；编辑于星期二\18点43分STEP#2–SimultaneousAorticandIVCAngiographyPower

inject

artery

below

SMA

(10ml

for

1

sec)Hand-inject

vein

simultaneously本文档共26页；当前第9页；编辑于星期二\18点43分STEP#3-PrepareCrossingSystem0.014”guidewire0.014”

to0.035”

wireconvertor0.035”microcatheterBack

endof0.014”guidewireElectrosurge

rypencilCOAXIAL•

Confienza

amputatedtip,••insideaPiggyback

wireconvertor,inside

aNavicross

braided0.035microcatheter,

to

deliverlater

Lunderquist

(or)•2x20mm

Advance

Micro14

tibial

balloon

inside

a

0.035

CXI

support

catheterELECTROSURGERY••Noshort

circuitsGround

pad

withoutinterposed

metallic

hips&pacemakers•50W“cutting”modeAdvanceMicro

142.9FID

compatible0.035”

CXIsupportcatheter本文档共26页；当前第10页；编辑于星期二\18点43分AoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViews

In

lateral

projection,

fine-tune

orientation

away

from

bowel

or

calcium

as

needed

Wire

tip

Piggyback

tip

DuodenumNavicross

tip

Different

patient本文档共26页；当前第11页；编辑于星期二\18点43分If

it

doesn’t

cross13Like

thisNot

like

thisSTEP#5-CrossingYour

target

maybe

too

calcific:re-positionorre-orientYourguidewiretip

maynotbeconductingcurrent:

Disconnected,

charred,

short-circuited,

etc.Only

attempt

for

about

1sec本文档共26页；当前第12页；编辑于星期二\18点43分STEP#6-SnaringandAdvancingasp

ic

position

Advance

in

tandem

withtraversal

wire

&

wire

convertor本文档共26页；当前第13页；编辑于星期二\18点43分STEP#7-SheathInsertionHemostasis

is

universalSide

arm

upforEdwardseSheathAdvancesheathinone

step本文档共26页；当前第14页；编辑于星期二\18点43分Sheath>18FrID<=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength>7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrent

Closure

Device

Algorithm本文档共26页；当前第15页；编辑于星期二\18点43分Place

buddy

wireInsert

deflectablesheathPassively

expose

aortic

discPosition

pigtailWithdraw

anddeflect

sheathtocrossingpointWithdrawTAVIsheath

intoIVCAdvance

pigtail

cephalad&testRetract

disc

ontoR

aorticwallStraighten

Agilis

during

withdrawalthroughtract

intocavaPullAmplatzer

cableto

reachcava,

then

push

cableto

re-formvenous

sideSTEP#9-Closure本文档共26页；当前第16页；编辑于星期二\18点43分Review

angio

beforerelease

cableand

buddywireIf

bleeding

–

Considerballoonaortic

tamponade

–

Consider

endograftClose

venous

accesssiteand

wait10

minutesRepeat

angiogramSTEP#10–CompletionAngiography本文档共26页；当前第17页；编辑于星期二\18点43分Patterns

of

Completion

Angiography

N=16Completeocclusion

N=16Caval-aortic

fistulawith

long

tunnel,

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本文档共26页；当前第18页；编辑于星期二\18点43分残余动静脉分流的转归本文档共26页；当前第19页；编辑于星期二\18点43分Transcaval

Access

for

TAVR

IDE

Registry

NIH

sponsored

-

site

monitoring,

DSMBoversight,CECadjudication

ofprimary

and

secondaryendpoints

20

sites,

100

patient,nonrandomized

prospective

registry;concomitantretrospectiveregistry

of

all

known

cases

Primary

endpoint:

“devicesuccess”

successfultranscavalaccessandclosure

withoutdeath

relatedto

accessor

closure

Enrollment

began10/2014

99/100

patients

enrolled本文档共26页；当前第20页；编辑于星期二\18点43分CenterHenry

Ford

Hospital1Detroit,

MITotal

79IDE

37Angiografia

de

Occidente2Cali,

Colombia15Detroit

Medical

CenterDetroit,MI3Spectrum

HealthGrand

Rapids,

MI1Emory

UniversityAtlanta,

GA2516University

of

UtahSalt

Lake

City,

UT2Oklahoma

HeartTulsa,

OK118BrighamandWomen’sBoston,MA1Columbia

UniversityNew

York,

NY21IDECenterGerman

Heart

CenterMunich,

GETotal

3Wake

Forest

Baptist

HealthWinston

Salem,

NC74Good

SamaritanCincinnati,

OH3Edward

HospitalNaperville,

IL54ClevelandClinicFoundationCleveland,

OH3University

of

VirginiaCharlottesville,

VA71York

HospitalYork,

PA33Toledo

HospitalToledo,OH31Vanderbilt

UniversityNashville,

TN53CenterSt.

Vincent’sHospitalIndianapolis,INTotal

2IDE

2Instituto

DantePazzanese

deCardiologia,Sao

Paulo,BR1TerreboneHospitalHouma,LA21Lexington

Medical

CenterColombia,

SC76WashingtonHospital

CenterWashington,DC11Ochsner

Medical

CenterNew

Orleans,

LA77London

Health

SciencesCtrLondon,ON1Carilion

MedicalCenterRoanoke,

VA22EvanstonHospitalChicago,

IL22Total21499Worldwide

Transcaval

TAVI

Experience

Status

as

of

2016Bold:

independently

performing本文档共26页；当前第21页；编辑于星期二\18点43分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本文档共26页；当前第22页；编辑于星期二\18点43分Transcaval

TAVR

Feasible,teachable,has

nowbeen

appliedto>200