（優(yōu)質(zhì)醫(yī)學(xué)）經(jīng)腔靜脈-主動脈入路TAV-.ppt

1、經(jīng)腔靜脈-主動脈入路TAVR,1,33.5%,Transfemoral 62.6%,手術(shù)入路 Transaortic 3.6% Subclavian 0.3% Transapical,2,手術(shù)入路,1、股動脈入路常常需要18F-22F鞘管，術(shù)后易出現(xiàn)血管并發(fā)癥，且髂動脈嚴(yán)重鈣化迂曲、血管直徑過小或者合并外周動脈疾病者存在禁忌。 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。,3,非股動脈入路的其他入路,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，在美國底特律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)隊決定實施首例人類腔靜脈-主動脈路徑TAVR手術(shù)，手術(shù)獲得了成功。,6,經(jīng)腔靜脈-主動脈路徑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