经腔静脉-主动脉入路TAVR

经腔静脉-主动脉入路TAVR33.5%Transfemoral62.6%手术入路Transaortic3.6%Subclavian0.3%Transapical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CarotiddirectaortictransapicalIliac-aorticconduitsTranscavalsubclavian/PercutaneousaxillaryNewer-ExtrathoracicHistorical-Intrathoracic2013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。经腔静脉-主动脉路径TAVRProcedureschematicA:CrossfromIVCthroughcalcium-freewindowintoprepositionedaorticsnareB:ExchangeforrigidguidewireC:DeliversheathandTAVRD:ClosewithnitinoloccluderProposedphysiologyRetroperitonealspacepressureishigherthanvein.AorticbleedingdecompressesthroughaholeinIVCintovasculatureRecommendation(CA-TAVReligibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mmAorticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxSTEP#1–ObtainCT-basedTreatmentPlanLederman,JACCImaging,2014MarcusChen,NHLBICoreLabSTEP#2–SimultaneousAorticandIVCAngiographyPowerinjectarterybelowSMA(10mlfor1sec)Hand-injectveinsimultaneouslySTEP#3-PrepareCrossingSystem0.014”guidewire0.014”to0.035”wireconvertor0.035”microcatheterBackendof0.014”guidewireElectrosurgerypencilCOAXIAL•Confienzaamputatedtip,••insideaPiggybackwireconvertor,insideaNavicrossbraided0.035microcatheter,todeliverlaterLunderquist(or)•2x20mmAdvanceMicro14tibialballooninsidea0.035CXIsupportcatheterELECTROSURGERY••NoshortcircuitsGroundpadwithoutinterposedmetallichips&pacemakers•50W“cutting”modeAdvanceMicro142.9FIDcompatible0.035”CXIsupportcatheterAoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViewsInlateralprojection,fine-tuneorientationawayfrombowelorcalciumasneededWiretipPiggybacktipDuodenumNavicrosstipDifferentpatientIfitdoesn’tcross13LikethisNotlikethisSTEP#5-CrossingYourtargetmaybetoocalcific:re-positionorre-orientYourguidewiretipmaynotbeconductingcurrent:Disconnected,charred,short-circuited,etc.Onlyattemptforabout1secSTEP#6-SnaringandAdvancingaspicpositionAdvanceintandemwithtraversalwire&wireconvertorSTEP#7-SheathInsertionHemostasisisuniversalSidearmupforEdwardseSheathAdvancesheathinonestepSheath18FrID=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrentClosureDeviceAlgorithmPlacebuddywireInsertdeflectablesheathPassivelyexposeaorticdiscPositionpigtailWithdrawanddeflectsheathtocrossingpointWithdrawTAVIsheathintoIVCAdvancepigtailcephalad&testRetractdiscontoRaorticwallStraightenAgilisduringwithdrawalthroughtractintocavaPullAmplatzercabletoreachcava,thenpushcabletore-formvenoussideSTEP#9-ClosureReviewangiobeforereleasecableandbuddywireIfbleeding–Considerballoonaortictamponade–ConsiderendograftClosevenousaccesssiteandwait10minutesRepeatangiogramSTEP#10–CompletionAngiographyPatternsofCompletionAngiographyN=16CompleteocclusionN=16Caval-aorticfistulawithlongtunnel,noextravasationN=42Caval-aorticfistula+“cruciform”extra-aorticcontrastN=5Extravasation(Endograft7hrs.later)Type0Type1Type2Type3MostcommonpatternOf79cases残余动静脉分流的转归TranscavalAccessforTAVRIDERegistryNIHsponsored-sitemonitoring,DSMBoversight,CECadjudicationofprimaryandsecondaryendpoints20sites,100patient,nonrandomizedprospectiveregistry;concomitantretrospectiveregistryofallknowncasesPrimaryendpoint:“devicesuccess”successfultranscavalaccessandclosurewithoutdeathrelatedtoaccessorclosureEnrollmentbegan10/201499/100patientsenrolledCenterHenryFordHospital1Detroit,MITotal79IDE37AngiografiadeOccidente2Cali,Colombia15DetroitMedicalCenterDetroit,MI3SpectrumHealthGrandRapids,MI1EmoryUniversityAtlanta,GA2516UniversityofUtahSaltLakeCity,UT2OklahomaHeartTulsa,OK118BrighamandWomen’sBoston,MA1ColumbiaUniversityNewYork,NY21IDECenterGermanHeartCenterMunich,GETotal3WakeForestBaptistHealthWinstonSalem,NC74GoodSamaritanCincinnati,OH3EdwardHospitalNaperville,IL54ClevelandClinicFoundationCleveland,OH3UniversityofVirginiaCharlottesville,VA71YorkHospitalYork,PA33ToledoHospitalToledo,OH31VanderbiltUniversityNashville,TN53CenterSt.Vincent’sHospitalIndianapolis,INTotal2IDE2InstitutoDantePazzanesedeCardiologia,SaoPaulo,BR1TerreboneHospitalHouma,LA21LexingtonMedicalCenterColombia,SC76WashingtonHospitalCenterWashington,DC11OchsnerMedicalCenterNewOrleans,LA77LondonHealthSciencesCtrLondon,ON1CarilionMedicalCenterRoanoke,VA22EvanstonHospitalChicago,IL22Total21499WorldwideTranscavalTAVIExperienceStatu