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1、经腔静脉经腔静脉- -主动脉入路主动脉入路TAVR133.5%Transfemoral62.6%手术入路手术入路Transaortic 3.6%Subclavian 0.3%Transapical2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。3非股动脉入路的其他入路非股动脉入路的其他入路CarotiddirectaortictransapicalIliac-aorticconduitsTranscavalsubclavian/
2、Percutaneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic452013年7月3日，在美国底特律HenryFord医院，Dr.Lederman和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。6经腔静脉经腔静脉- -主动脉路径主动脉路径TAVRTAVRProcedure schematicA: Cross from IVC throu
3、gh 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 vasculature7Recommendation(CA-TAVRe
4、ligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mm
5、Aorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxST
6、EP #1 Obtain CT-based Treatment PlanLederman, JACC Imaging, 2014Marcus Chen, NHLBI Core Lab8STEP #2 Simultaneous Aortic and IVC AngiographyPower inject artery below SMA (10ml for 1 sec)Hand-inject vein simultaneously9STEP #3 - Prepare Crossing System0.014”guidewire0.014” to0.035” wireconvertor0.035”
7、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 short circ
8、uitsGround pad withoutinterposed metallic hips &pacemakers50W “cutting” modeAdvance Micro 142.9F ID compatible0.035” CXI support catheter10AoIVCSTEP #4 Align Guiding Catheter in Orthogonal ViewsIn lateral projection, fine-tuneorientation away from bowel orcalcium as neededWire tipPiggyback tipDuoden
9、umNavicross tipDifferent patient11If 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 1sec12STEP #6 - Snaring and Advan
10、cingasp ic positionAdvance in tandem withtraversal wire & wire convertor13STEP #7 - Sheath InsertionHemostasis is universalSide arm up forEdwards eSheathAdvance sheath in one step14Sheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP #8 Select a Closure DeviceCu
11、rrent Closure Device Algorithm15Place 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
12、 into cavaPull Amplatzer cable to reachcava, then push cable to re-formvenous sideSTEP # 9 - Closure16Review angio beforerelease cable and buddywireIf bleeding Consider balloon aortictamponade Consider endograftClose venous access siteand wait 10 minutesRepeat angiogramSTEP #10 Completion Angiograph
13、y17Patterns 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 cases18残余动静脉分流的转归残余动静脉分流的转归19Transcaval
14、 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” successful transcaval acce
15、ss andclosure without death related to access or closureEnrollment began 10/201499/100 patients enrolled20CenterHenry Ford Hospital1Detroit, MITotal79IDE37Angiografia de Occidente2Cali, Colombia15Detroit Medical CenterDetroit, MI3Spectrum HealthGrand Rapids, MI1Emory UniversityAtlanta, GA2516Univers
16、ity 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 Clinic FoundationClevel
17、and, OH3University of VirginiaCharlottesville, VA71York HospitalYork, PA33Toledo HospitalToledo, OH31Vanderbilt UniversityNashville, TN53CenterSt. Vincents HospitalIndianapolis, INTotal2IDE2Instituto Dante Pazzanese deCardiologia, Sao Paulo, BR1Terrebone HospitalHouma, LA21Lexington Medical CenterCo
18、lombia, SC76Washington Hospital CenterWashington, DC11Ochsner Medical CenterNew Orleans, LA77London Health Sciences CtrLondon, ON1Carilion Medical CenterRoanoke, VA22Evanston HospitalChicago, IL22Total21499Worldwide TranscavalTAVI ExperienceStatus as of 2016Bold: independently performing21Conclusion
19、s: 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 cohort. Compared with low
20、er-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 t
21、he procedure and reduce bleeding22Transcaval TAVR 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
22、IDE using Amplatzerdevices is 99% completed Dedicated closure devices to achieve immediatehemostasis are in development23Caval-Aortic Access Future 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?2425谢谢您的聆听26
