经腔静脉主动脉入路TAVR.pptx

经腔静脉经腔静脉-主动脉入路主动脉入路TAVR经腔静脉主动脉入路TAVR第1页33.5%Transfemoral62.6%手术入路手术入路Transaortic 3.6%Subclavian 0.3%Transapical经腔静脉主动脉入路TAVR第2页手术入路手术入路1、股动脉入路经常需要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、包含经心尖在内经胸腔入路，术后恢复慢，且伴随更多术后并发症。经腔静脉主动脉入路TAVR第3页非股动脉入路其它入路非股动脉入路其它入路CarotiddirectaortictransapicalIliac-aorticconduitsTranscavalsubclavian/Percutaneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic经腔静脉主动脉入路TAVR第4页经腔静脉主动脉入路TAVR第5页年7月3日，在美国底特律Henry Ford医院，Dr.Lederman和Dr.Greenbaum以及他们同事们，采取该术式为一位80岁女性患者成功进行了TAVR。术前，其它介入路径，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，所以手术团体决定实施首例人类腔静脉-主动脉路径TAVR手术，手术取得了成功。经腔静脉主动脉入路TAVR第6页经腔静脉经腔静脉-主动脉路径主动脉路径TAVRTAVRProcedure schematicA: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 vasculature经腔静脉主动脉入路TAVR第7页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.-xx-xxSTEP#1 Obtain CT-based Treatment PlanLederman,JACC Imaging,Marcus Chen,NHLBI Core Lab经腔静脉主动脉入路TAVR第8页STEP#2 Simultaneous Aortic and IVC AngiographyPower inject artery below SMA(10ml for 1 sec)Hand-inject vein simultaneously经腔静脉主动脉入路TAVR第9页STEP#3-Prepare Crossing 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 inside a0.035 CXI support catheterELECTROSURGERYNo short circuitsGround pad withoutinterposed metallic hips&pacemakers50W“cutting”modeAdvance Micro 142.9F ID compatible0.035”CXI support catheter经腔静脉主动脉入路TAVR第10页AoIVCSTEP#4 Align Guiding Catheter in Orthogonal ViewsIn lateral projection,fine-tuneorientation away from bowel orcalcium as neededWire tipPiggyback tipDuodenumNavicross tipDifferent patient经腔静脉主动脉入路TAVR第11页If it doesnt cross13Like thisNot like thisSTEP#5-CrossingYour target may be too calcific:re-position or re-orientYour guidewire tip may not be conducting current:Disconnected,charred,short-circuited,etc.Only attempt for about 1sec经腔静脉主动脉入路TAVR第12页STEP#6-Snaring and Advancingasp ic positionAdvance in tandem withtraversal wire&wire convertor经腔静脉主动脉入路TAVR第13页STEP#7-Sheath InsertionHemostasis is universalSide arm up forEdwards eSheathAdvance sheath in one step经腔静脉主动脉入路TAVR第14页Sheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8 Select a Closure DeviceCurrent Closure Device Algorithm经腔静脉主动脉入路TAVR第15页Place buddy wireInsert deflectable sheathPassively expose aortic discPosition pigtailWithdraw 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-Closure经腔静脉主动脉入路TAVR第16页Review angio beforerelease cable and buddywireIf bleeding Consider balloon aortictamponade Consider endograftClose venous access siteand wait 10 minutesRepeat angiogramSTEP#10 Completion Angiography经腔静脉主动脉入路TAVR第17页Patterns of Completion AngiographyN=16Complete occlusionN=16Caval-aortic fistula withlong tunnel,no extravasationN=42Caval-aortic fistula+“cruciform”extra-aorticcontrastN=5Extravasation(Endograft 7 hrs.later)Type 0Type 1Type 2Type 3MostcommonpatternOf 79 cases经腔静脉主动脉入路TAVR第18页残余动静脉分流转归残余动静脉分流转归经腔静脉主动脉入路TAVR第19页Transcaval Access for TAVR IDE RegistryNIH sponsored-site monitoring,DSMB oversight,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 10/99/100 patients enrolled经腔静脉主动脉入路TAVR第20页CenterHenry Ford Hospital1Detroit,MITotal79IDE37Angiografia de Occidente2Cali,Colombia15Detroit Medical CenterDetroit,MI3Spectrum HealthGrand Rapids,MI1Emory UniversityAtlanta,GA2516University of UtahSalt Lake City,UT2Oklahoma HeartTulsa,OK118Brigham and WomensBoston,MA1Columbia UniversityNew York,NY21IDECenterGerman Heart CenterMunich,GETotal3Wake Forest Baptist HealthWinston Salem,NC74Good SamaritanCincinnati,OH3Edward HospitalNaperville,IL54Cleveland Clinic FoundationCleveland,OH3University of VirginiaCharlottesville,VA71York HospitalYork,PA33Toledo HospitalToledo,OH31Vanderbilt UniversityNashville,TN53CenterSt.Vincents HospitalIndianapolis,INTotal2IDE2Instituto Dante Pazzanese deCardiologia,Sao Paulo,BR1Terrebone HospitalHouma,LA21Lexington Medical CenterColombia,SC76Washington Hospital CenterWashington,DC11Ochsner Medical CenterNew Orleans,LA77London Health Sciences CtrLondon,ON1Carilion Medical CenterRoanoke,VA22Evanston HospitalChicago,IL22Total21499Worldwide TranscavalTAVI ExperienceStatus as of Bold:independently performing经腔静脉主动脉入路TAVR第21页Conclusions:Transcaval TAVR Transcaval access enabled TAVR 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,transcavalbleeding 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 bleeding经腔静脉主动脉入路TAVR第22页Transcaval TAVR Feasible,teachable,has now been applied to 200 pts todate but should be planned carefully;we recommendproctoring Bleeding and transfusion are now much less common andsimilar to transfemoral TAVR as is length of stay NHLBI sponsored US multicenter IDE using Amplatzerdevices is 99%completed Dedicated closure devices to achieve immediatehemostasis are in development经腔静脉主动脉入路TAVR第23页Caval-Aortic Access Future Directions Caval-aortic access has now been utilized for TEVAR,temporary LV assist device placement for cardiogenicshock and PCI May have a role in other trans-catheter treatments:Large devices for aortic insufficiency?Pediatric uses?Devices yet invented?ledermannih.gov经腔静脉主动脉入路TAVR第24页经腔静脉主动脉入路TAVR第25页谢谢您聆听经腔静脉主动脉入路TAVR第26页