经腔静脉-主动脉入路TAVR课件.ppt

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

14、o cavaPull Amplatzer cable to reachcava,then push cable to re-formvenous sideSTEP#9-ClosureSTEP#9-ClosureReview angio beforerelease cable and buddywireIf bleeding Consider balloon aortictamponade Consider endograftClose venous access siteand wait 10 minutesRepeat angiogramSTEP#10 Completion Angiogra

15、phySTEP#10 Completion AngiographyPatternsPatterns ofof CompletionCompletion AngiographyAngiographyN=16Complete occlusionN=16Caval-aortic fistula withlong tunnel,no extravasationN=42Caval-aortic fistula+“cruciform”extra-aorticcontrastN=5Extravasation(Endograft 7 hrs.later)Type 0Type 1Type 2Type 3Most

16、commonpatternOfOf 7979 casescases残余动静脉分流的转归残余动静脉分流的转归TranscavalTranscaval AccessAccess forfor TAVRTAVR IDEIDE RegistryRegistryNIH sponsored-site monitoring,DSMB oversight,CEC adjudication ofprimary and secondary endpoints20 sites,100 patient,nonrandomized prospective registry;concomitantretrospectiv

17、e registry of all known casesPrimary endpoint:“device success”successful transcaval access andclosure without death related to access or closureEnrollment began 10/201499/100 patients enrolledCenterCenterHenryHenry FordFord HospitalHospital1 1Detroit,Detroit,MIMITotalTotal7979IDEIDE3737AngiografiaAn

18、giografia dede OccidenteOccidente2 2Cali,Cali,ColombiaColombia1515Detroit Medical CenterDetroit,MI3Spectrum HealthGrand Rapids,MI1EmoryEmory UniversityUniversityAtlanta,Atlanta,GAGA25251616University of UtahSalt Lake City,UT2OklahomaOklahoma HeartHeartTulsa,Tulsa,OKOK11118 8Brigham and WomensBoston,

19、MA1Columbia UniversityNew York,NY21IDEIDECenterCenterGermanGerman HeartHeart CenterCenterMunich,Munich,GEGETotalTotal3 3WakeWake ForestForest BaptistBaptist HealthHealthWinstonWinston Salem,Salem,NCNC7 74 4GoodGood SamaritanSamaritanCincinnati,Cincinnati,OHOH3 3EdwardEdward HospitalHospitalNapervill

20、e,Naperville,ILIL5 54 4Cleveland Clinic FoundationCleveland,OH3UniversityUniversity ofof VirginiaVirginiaCharlottesville,Charlottesville,VAVA7 71 1York HospitalYork,PA33Toledo HospitalToledo,OH31VanderbiltVanderbilt UniversityUniversityNashville,Nashville,TNTN5 53 3CenterCenterSt.Vincents HospitalIn

21、dianapolis,INTotalTotal2IDEIDE2Instituto Dante Pazzanese deCardiologia,Sao Paulo,BR1Terrebone HospitalHouma,LA21LexingtonLexington MedicalMedical CenterCenterColombia,Colombia,SCSC7 76 6Washington Hospital CenterWashington,DC11OchsnerOchsner MedicalMedical CenterCenterNewNew Orleans,Orleans,LALA7 77

22、 7London Health Sciences CtrLondon,ON1Carilion Medical CenterRoanoke,VA22Evanston HospitalChicago,IL22TotalTotal2142149999WorldwideWorldwide TranscavalTranscavalTAVITAVI ExperienceExperienceStatus as of 2016BoldBold:independently performingConclusions:Transcaval TAVR Transcaval access enabled TAVR i

23、n 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

24、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 bleedingTranscavalTranscaval TA

25、VRTAVR 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 Ded

26、icated closure devices to achieve immediatehemostasis are in developmentCaval-AorticCaval-Aortic AccessAccess Future DirectionsFuture 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谢谢您的聆听谢谢您的聆听