（优质课件）经腔静脉-主动脉入路TAVR

1、经腔静脉-主动脉入路TAVR,1,33.5%,Transfemoral 62.6%,手术入路 Transaortic 3.6% Subclavian 0.3% Transapical,2,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,非股动脉入路的其他入路,Carotid direct,aortic transapical Iliac-aortic conduits Transcaval,subclavian/ Percuta

2、neous axillary,Newer-Extrathoracic,Historical-Intrathoracic,4,5,2013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-主动脉路径TAVR,Procedure schematic A: Cross from IVC through calcium

3、-free window into prepositioned aortic snare B: Exchange for rigid guidewire C: Deliver sheath and TAVR D: Close with nitinol occluder,Proposed physiology Retroperitoneal space pressure is higher than vein. Aortic bleeding decompresses through a hole in IVC into vasculature,7,STEP #1 Obtain CT-based

4、 Treatment Plan,Lederman, JACC Imaging, 2014 Marcus Chen, NHLBI Core Lab,8,STEP #2 Simultaneous Aortic and IVC Angiography,Power inject artery below SMA (10ml for 1 sec) Hand-inject vein simultaneously,9,STEP #3 - Prepare Crossing System,0.014” guidewire 0.014” to 0.035” wire convertor,0.035” microc

5、atheter,Back end of 0.014” guidewire,Electrosurge,ry pencil,COAXIAL Confienza amputated tip, ,inside a Piggyback wire convertor, inside a Navicross braided 0.035 microcatheter, to deliver later Lunderquist (or),2x20mm Advance Micro 14 tibial balloon inside a,0.035 CXI support catheter ELECTROSURGERY

6、, ,No short circuits Ground pad without interposed metallic hips concomitant retrospective registry of all known cases Primary endpoint: “device success” successful transcaval access and closure without death related to access or closure Enrollment began 10/2014 99/100 patients enrolled,20,Center He

7、nry Ford Hospital1,Detroit, MI,Total 79,IDE 37,Angiografia de Occidente2,Cali, Colombia,15,Detroit Medical Center,Detroit, MI,3,Spectrum Health,Grand Rapids, MI,1,Emory University,Atlanta, GA,25,16,University of Utah,Salt Lake City, UT,2,Oklahoma Heart,Tulsa, OK,11,8,Brigham and Womens,Boston, MA,1,

8、Columbia University,New York, NY,2,1,IDE,Center German Heart Center,Munich, GE,Total 3,Wake Forest Baptist Health,Winston Salem, NC,7,4,Good Samaritan,Cincinnati, OH,3,Edward Hospital,Naperville, IL,5,4,Cleveland Clinic Foundation,Cleveland, OH,3,University of Virginia,Charlottesville, VA,7,1,York H

9、ospital,York, PA,3,3,Toledo Hospital,Toledo, OH,3,1,Vanderbilt University,Nashville, TN,5,3,Center St. Vincents Hospital,Indianapolis, IN,Total 2,IDE 2,Instituto Dante Pazzanese de,Cardiologia, Sao Paulo, BR,1,Terrebone Hospital,Houma, LA,2,1,Lexington Medical Center,Colombia, SC,7,6,Washington Hosp

10、ital Center,Washington, DC,1,1,Ochsner Medical Center,New Orleans, LA,7,7,London Health Sciences Ctr,London, ON,1,Carilion Medical Center,Roanoke, VA,2,2,Evanston Hospital,Chicago, IL,2,2,Total,214,99,Worldwide Transcaval TAVI Experience Status as of 2016,Bold: independently performing,21,Conclusion

11、s: 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

12、 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 si

13、mplify the procedure and reduce bleeding,22,Transcaval TAVR, Feasible, teachable, has now been applied to 200 pts to,date but should be planned carefully; we recommend proctoring, Bleeding and transfusion are now much less common and,similar to transfemoral TAVR as is length of stay, NHLBI sponsored US multicenter IDE using Amplatzer,devices is 99% completed, Dedicated closure devices to achieve immediate,hemostasis are in development,23,Caval-Aortic Access Future Directions Caval-aortic access has now been utilized for TEVAR, temporary L