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1、1經(jīng)腔靜脈經(jīng)腔靜脈- -主動(dòng)脈入路主動(dòng)脈入路TAVR233.5%Transfemoral62.6%手術(shù)入路手術(shù)入路Transaortic 3.6%Subclavian 0.3%Transapical3手術(shù)入路手術(shù)入路1、股動(dòng)脈入路常常需要18F-22F鞘管,術(shù)后易出現(xiàn)血管并發(fā)癥,且髂動(dòng)脈嚴(yán)重鈣化迂曲、血管直徑過小或者合并外周動(dòng)脈疾病者存在禁忌。2、包括經(jīng)心尖在內(nèi)的經(jīng)胸腔入路,術(shù)后恢復(fù)慢,且伴隨更多的術(shù)后并發(fā)癥。4非股動(dòng)脈入路的其他入路非股動(dòng)脈入路的其他入路CarotiddirectaortictransapicalIliac-aorticconduitsTranscavalsubclavian
2、/Percutaneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic562013年7月3日,在美國(guó)底特律Henry Ford醫(yī)院,Dr. Lederman和Dr. Greenbaum以及他們的同事們,采用該術(shù)式為一位80歲女性患者成功進(jìn)行了TAVR。術(shù)前,其他介入路徑,如經(jīng)股動(dòng)脈、經(jīng)心尖、經(jīng)鎖骨下等在這位患者身上均嘗試失敗,因此手術(shù)團(tuán)隊(duì)決定實(shí)施首例人類腔靜脈-主動(dòng)脈路徑TAVR手術(shù),手術(shù)獲得了成功。7經(jīng)腔靜脈經(jīng)腔靜脈- -主動(dòng)脈路徑主動(dòng)脈路徑TAVRTAVRProcedure schematicA: Cross from IVC t
3、hrough 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 vasculature8Recommendation(CA-T
4、AVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter
5、23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014
6、-xx-xxSTEP #1 Obtain CT-based Treatment PlanLederman, JACC Imaging, 2014Marcus Chen, NHLBI Core Lab9STEP #2 Simultaneous Aortic and IVC AngiographyPower inject artery below SMA (10ml for 1 sec)Hand-inject vein simultaneously10STEP #3 - Prepare Crossing System0.014”guidewire0.014” to0.035” wireconver
7、tor0.035”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 s
8、hort circuitsGround pad withoutinterposed metallic hips &pacemakers50W “cutting” modeAdvance Micro 142.9F ID compatible0.035” CXI support catheter11AoIVCSTEP #4 Align Guiding Catheter in Orthogonal ViewsIn lateral projection, fine-tuneorientation away from bowel orcalcium as neededWire tipPiggyb
9、ack tipDuodenumNavicross tipDifferent patient12If 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 1sec13STEP #6 - Snar
10、ing and Advancingasp ic positionAdvance in tandem withtraversal wire & wire convertor14STEP #7 - Sheath InsertionHemostasis is universalSide arm up forEdwards eSheathAdvance sheath in one step15Sheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP #8 Select a
11、 Closure DeviceCurrent Closure Device Algorithm16Place 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 wi
12、thdrawalthrough tract into cavaPull Amplatzer cable to reachcava, then push cable to re-formvenous sideSTEP # 9 - Closure17Review angio beforerelease cable and buddywireIf bleeding Consider balloon aortictamponade Consider endograftClose venous access siteand wait 10 minutesRepeat angiogramSTEP #10
13、Completion Angiography18Patterns 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 cases19殘余動(dòng)靜脈分流的轉(zhuǎn)歸殘
14、余動(dòng)靜脈分流的轉(zhuǎn)歸20Transcaval 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” succe
15、ssful transcaval access andclosure without death related to access or closureEnrollment began 10/201499/100 patients enrolled21CenterHenry Ford Hospital1Detroit, MITotal79IDE37Angiografia de Occidente2Cali, Colombia15Detroit Medical CenterDetroit, MI3Spectrum HealthGrand Rapids, MI1Emory UniversityA
16、tlanta, 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 Cl
17、inic FoundationCleveland, OH3University of VirginiaCharlottesville, VA71York HospitalYork, PA33Toledo HospitalToledo, OH31Vanderbilt UniversityNashville, TN53CenterSt. Vincents HospitalIndianapolis, INTotal2IDE2Instituto Dante Pazzanese deCardiologia, Sao Paulo, BR1Terrebone HospitalHouma, LA21Lexin
18、gton Medical CenterColombia, SC76Washington Hospital CenterWashington, DC11Ochsner Medical CenterNew Orleans, LA77London Health Sciences CtrLondon, ON1Carilion Medical CenterRoanoke, VA22Evanston HospitalChicago, IL22Total21499Worldwide TranscavalTAVI ExperienceStatus as of 2016Bold: independently p
19、erforming22Conclusions: 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 coho
20、rt. 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 bleeding23Transcaval TAVR Feasible, teachable, has n
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