經(jīng)腔靜脈-主動(dòng)脈入路TAVR課件

1、經(jīng)腔靜脈-主動(dòng)脈入路TAVR經(jīng)腔靜脈-主動(dòng)脈入路TAVR33.5%Transfemoral62.6%手術(shù)入路Transaortic 3.6%Subclavian 0.3%Transapical33.5%Transfemoral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。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)非股動(dòng)脈入路的其他入路CarotiddirectaortictransapicalIliac-aor

2、ticconduitsTranscavalsubclavian/Percutaneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic非股動(dòng)脈入路的其他入路Carotidaorticsubcl經(jīng)腔靜脈-主動(dòng)脈入路TAVR2013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(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

3、了成功。2013年7月3日，在美國底特律Henry Ford醫(yī)院，D經(jīng)腔靜脈-主動(dòng)脈路徑TAVRProcedure 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.

4、Aortic bleeding decompresses through a hole in IVCinto vasculature經(jīng)腔靜脈-主動(dòng)脈路徑TAVRProcedure schemRecommendation(CA-TAVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm

5、(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotarget

6、centerlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxSTEP #1 Obtain CT-based Treatment PlanLederman, JACC Imaging, 2014Marcus Chen, NHLBI Core LabRecommendation(CA-TAVReligibilSTEP #2 Simultaneous Aortic and IVC AngiographyPower inject a

7、rtery below SMA (10ml for 1 sec)Hand-inject vein simultaneouslySTEP #2 Power inject artery STEP #3 - Prepare Crossing System0.014”guidewire0.014” to0.035” wireconvertor0.035”microcatheterBack end of0.014”guidewireElectrosurgerypencilCOAXIAL Confienza amputated tip,inside aPiggyback wire convertor,in

8、side 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 suppo

9、rt catheterSTEP #3 - Prepare Crossing SysAoIVCSTEP #4 Align Guiding Catheter in Orthogonal ViewsIn lateral projection, fine-tuneorientation away from bowel orcalcium as neededWire tipPiggyback tipDuodenumNavicross tipDifferent patientAoIVCSTEP #4 Navicross tipIf it doesnt cross13Like thisNot like th

10、isSTEP #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 1secIf it doesnt cross13Like thisSTEP #6 - Snaring and Advancingasp ic positionAdvance in tandem withtraver

11、sal wire & wire convertorSTEP #6 - Snaring and AdvancinSTEP #7 - Sheath InsertionHemostasis is universalSide arm up forEdwards eSheathAdvance sheath in one stepSTEP #7 - Sheath InsertionHemoSheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP #8 Select a Closure

12、 DeviceCurrent Closure Device AlgorithmSheath18FrID200 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 developmentTranscaval TAVR Feasible, tCaval-Aortic Access Future Directions Caval-aortic access has now been utilized for TEVAR,temporary LV assist device placement for cardiogenicshock an