经腔静脉主动脉入路TAVR培训课件.ppt

1、本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。33.5%Transfemoral62.6%手术入路手术入路Transaortic 3.6%Subclavian 0.3%Transapical本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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。本文档所提供的信息仅供参考之用，不能作为科学依据，

2、请勿模仿；如有不当之处，请联系网站或本人删除。非股动脉入路的其他入路非股动脉入路的其他入路CarotiddirectaortictransapicalIliac-aorticconduitsTranscavalsubclavian/Percutaneous axillaryNewer-ExtrathoracicHistorical-Intrathoracic本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2013年7月3日，在美国底特律Henry Fo

3、rd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。本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。经腔静脉经腔静脉-主动脉路径主动脉路径TAVRTAVRProcedure schematicA:Cross from IVC through calcium-freewindow into prepositioned aort

4、ic 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 vasculature本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Recommendation(CA-TAVRel

5、igibility)Favorable;Uncertain;Unfavorable2+AorticCa/thickening/ectasiaAorticcalciumgrade2TargetentrysitelumbarvertebraMidBodyL3(L3.0)OrthogonalprojectionAPCaval-aorticdistanceX-Y6mm(including1mmnon-calcifiedatheroma)InterposedstructuresnoneNearbystructuresBowelanteriortotargetCavallumendiameter23mmA

6、orticlumendiameter(+3/0/-1.2cm)15mm/16mm/14mmTargetdistanceaboveaorto-iliacbifurcation12mmTargetdistancebelowRrenalartery75mmEndograftbailoutlimbaccessRCIA5.2mm,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveat&Comments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxSTE

7、P#1 Obtain CT-based Treatment PlanLederman,JACC Imaging,2014Marcus Chen,NHLBI Core Lab本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。STEP#2 Simultaneous Aortic and IVC AngiographyPower inject artery below SMA(10ml for 1 sec)Hand-inject vein simultaneously本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本

8、人删除。STEP#3-Prepare Crossing System0.014”guidewire0.014”to0.035”wireconvertor0.035”microcatheterBack end of0.014”guidewireElectrosurgerypencilCOAXIAL Confienza amputated tip,inside aPiggyback wire convertor,inside aNavicross braided 0.035microcatheter,to deliverlater Lunderquist(or)2x20mm Advance Mic

9、ro14 tibial balloon inside a0.035 CXI support catheterELECTROSURGERYNo short circuitsGround pad withoutinterposed metallic hips&pacemakers50W“cutting”modeAdvance Micro 142.9F ID compatible0.035”CXI support catheter本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。AoIVCSTEP#4 Align Guiding Catheter in

10、Orthogonal ViewsIn lateral projection,fine-tuneorientation away from bowel orcalcium as neededWire tipPiggyback tipDuodenumNavicross tipDifferent patient本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。If it doesnt cross13Like thisNot like thisSTEP#5-CrossingYour target may be too calcific:re-positio

11、n or re-orientYour guidewire tip may not be conducting current:Disconnected,charred,short-circuited,etc.Only attempt for about 1sec本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。STEP#6-Snaring and Advancingasp ic positionAdvance in tandem withtraversal wire&wire convertor本文档所提供的信息仅供参考之用，不能作为科学依据，请勿

12、模仿；如有不当之处，请联系网站或本人删除。STEP#7-Sheath InsertionHemostasis is universalSide arm up forEdwards eSheathAdvance sheath in one step本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Sheath18FrID7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8 Select a Closure DeviceCurrent Closu

13、re Device Algorithm本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Place 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 Agil

14、is during withdrawalthrough tract into cavaPull Amplatzer cable to reachcava,then push cable to re-formvenous sideSTEP#9-Closure本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Review angio beforerelease cable and buddywireIf bleeding Consider balloon aortictamponade Consider endograftClose venous ac

15、cess siteand wait 10 minutesRepeat angiogramSTEP#10 Completion Angiography本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Patterns of Completion AngiographyN=16Complete occlusionN=16Caval-aortic fistula withlong tunnel,no extravasationN=42Caval-aortic fistula+“cruciform”extra-aorticcontrastN=5Extrav

16、asation(Endograft 7 hrs.later)Type 0Type 1Type 2Type 3MostcommonpatternOf 79 cases本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。残余动静脉分流的转归残余动静脉分流的转归本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Transcaval Access for TAVR IDE RegistryNIH sponsored-site monitoring,DSMB oversight,CEC adjudication o

17、fprimary and secondary endpoints20 sites,100 patient,nonrandomized prospective registry;concomitantretrospective registry of all known casesPrimary endpoint:“device success”successful transcaval access andclosure without death related to access or closureEnrollment began 10/201499/100 patients enrol

18、led本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。CenterHenry Ford Hospital1Detroit,MITotal79IDE37Angiografia de Occidente2Cali,Colombia15Detroit Medical CenterDetroit,MI3Spectrum HealthGrand Rapids,MI1Emory UniversityAtlanta,GA2516University of UtahSalt Lake City,UT2Oklahoma HeartTulsa,OK118Brigha

19、m and WomensBoston,MA1Columbia UniversityNew York,NY21IDECenterGerman Heart CenterMunich,GETotal3Wake Forest Baptist HealthWinston Salem,NC74Good SamaritanCincinnati,OH3Edward HospitalNaperville,IL54Cleveland Clinic FoundationCleveland,OH3University of VirginiaCharlottesville,VA71York HospitalYork,P

20、A33Toledo HospitalToledo,OH31Vanderbilt UniversityNashville,TN53CenterSt.Vincents HospitalIndianapolis,INTotal2IDE2Instituto Dante Pazzanese deCardiologia,Sao Paulo,BR1Terrebone HospitalHouma,LA21Lexington Medical CenterColombia,SC76Washington Hospital CenterWashington,DC11Ochsner Medical CenterNew

21、Orleans,LA77London Health Sciences CtrLondon,ON1Carilion Medical CenterRoanoke,VA22Evanston HospitalChicago,IL22Total21499Worldwide TranscavalTAVI ExperienceStatus as of 2016Bold:independently performing本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Conclusions:Transcaval TAVR Transcaval access ena

22、bled 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 lower-risk patients in PARTNER-II,transcavalbl

23、eeding 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 bleeding本文档所提供的信息仅供参

24、考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Transcaval 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 I

25、DE using Amplatzerdevices is 99%completed Dedicated closure devices to achieve immediatehemostasis are in development本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Caval-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?ledermannih.gov本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。谢谢您的聆听