经腔静脉-主动脉入路TAVR课件.ppt
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- 静脉 主动脉 TAVR 课件
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1、经腔静脉经腔静脉-主动脉入路主动脉入路TAVRTAVR33.5%33.5%TransfemoralTransfemoral62.6%62.6%手术入路手术入路TransaorticTransaortic 3.6%3.6%SubclavianSubclavian 0.3%0.3%TransapicalTransapical手术入路手术入路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。非股动脉入路的其他入路非股动脉入路的其他入路CarotidCar
2、otiddirectdirectaorticaortictransapicaltransapicalIliac-aorticIliac-aorticconduitsconduitsTranscavalTranscavalsubclavian/subclavian/PercutaneousPercutaneous axillaryaxillaryNewer-ExtrathoracicNewer-ExtrathoracicHistorical-IntrathoracicHistorical-Intrathoracic2013年7月3日,在美国底特律Henry Ford医院,Dr.Lederman和
3、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。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:
4、Close with nitinol occluderProposed physiologyRetroperitoneal space pressure is higher than vein.Aortic bleeding decompresses through a hole in IVCinto vasculatureRecommendation(CA-TAVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2Targetentrysitelumbarver
5、tebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRren
6、alartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxSTEPSTEP#1#1 ObtainObtain CT-basedCT-based TreatmentTreatment PlanPlanLederman,Lederman,JACCJACC Imaging,Imaging,201
7、42014MarcusMarcus Chen,Chen,NHLBINHLBI CoreCore LabLabSTEP#2 STEP#2 Simultaneous Aortic and IVC AngiographySimultaneous Aortic and IVC AngiographyPower inject artery below SMA(10ml for 1 sec)Hand-inject vein simultaneouslySTEP#3-Prepare Crossing SystemSTEP#3-Prepare Crossing System0.014”guidewire0.0
8、14”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 cathet
9、erELECTROSURGERYNo short circuitsGround pad withoutinterposed metallic hips&pacemakers50W“cutting”modeAdvance Micro 142.9F ID compatible0.035”CXI support catheterAoIVCSTEP#4 STEP#4 Align Guiding Catheter in Orthogonal ViewsAlign Guiding Catheter in Orthogonal ViewsIn lateral projection,fine-tuneorie
10、ntation away from bowel orcalcium as neededWire tipPiggyback tipDuodenumNavicross tipDifferentDifferent patientpatientIfIf itit doesntdoesnt crosscross13LikeLike thisthisNotNot likelike thisthisSTEP#5-CrossingSTEP#5-CrossingYour target may be too calcific:re-position or re-orientYour guidewire tip m
11、ay not be conducting current:Disconnected,charred,short-circuited,etc.Only attempt for about 1secSTEP#6-Snaring and AdvancingSTEP#6-Snaring and Advancingaspasp icic positionpositionAdvanceAdvance inin tandemtandem withwithtraversaltraversal wirewire&wirewire convertorconvertorSTEP#7-Sheath Insertion
12、STEP#7-Sheath InsertionHemostasisHemostasis isis universaluniversalSide arm up forEdwards eSheathAdvance sheath in one stepSheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8 Select a Closure DeviceSTEP#8 Select a Closure DeviceCurrentCurrent ClosureClosure D
13、eviceDevice AlgorithmAlgorithmPlace 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 int
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