经腔静脉-主动脉入路TAVR(共26张PPT)
合集下载
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
6• mPm▪uArpmopsClea-tlbzouesirltecvloesnuoreudseavcicceessasresiutender development that may Of 79 casaensd wait 10 minutes
University of Virginia
非股▪动脉入R路ep的ea其t a他n入gi路ogram
RCIA5.2mm,LCIA3.0mm 24cm 15x20mmtargetwindow Yes MChenread.2014-xx-xx
Lederman, JACC Imaging, 2014
Marcus Chen, NHLBI Core Lab
STEP #2 –
Simultaneous Aortic and IVC Angiography
Targetdistanceaboveaorto-iliacbifurcation
TargetdistancebelowRrenal artery Endograftbailoutlimbaccess CFVtotargetcenterlinedistance Caveat&Comments
LiesflatontheCTscanner? ReviewersNHLBI
CPiagrgil▪yiobnacMkRetdiepivcaileCwenatnergio before No short crierclueiatsse cable and buddy
Advance sheath in one step
Historical-wInitrraethoracic
DAoertrti▪ociltuMmeeIdfnidcbiaallemCeeedtneitrne(+rg3/0/-1.
Patterns of Completion Angiography
Type 0
Type 1
Type 2
Type 3
N=16
Complete occlusion
Most common pattern
N=16
N=42
Caval-aortic fistula with
long tunnel,
no extravasation
Only attempt for about 1sec
If it doesn’t cross
▪ Your target may be too calcific: re-position or reorient
▪ Your guidewire tip may not be conducting current:
Repeat angiogram
temporary LV assist device placement for cardiogenic
no extravasation 经腔静脉-主动脉路径TAVR
Transaortic 3.
Caveat&Comments
Transaortic 3.
Advance pigtail cephalad & test
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
Historical-Intrathoracic
Newer-Extrathoracic
Carotid direct
aortic
subclavian/
Percutaneous axillary
transapical
Wire tip
In lateral projection, fine-tune orientation away from bowel or
calcium as needed
Piggyback tip
Navicross tip
Duodenum Ao
IVC
Different patient
STEP #5 - Crossing
STEP #7 - Sheath Insertion
Advance sheath in one step Side arm up for
Edwards eSheath
Hemostasis is universal
STEP #8 – Select a Closure Device
Current Closure Device Algorithm
Sheath Aorto-cavaltract length≤7mm
Aorto-cavaltract length>7mm
>18FrID 8mmAmplatzer MuscularVSD Occluder
10/8AmplatzerDuct Occludergeneration1
<=18FrID 6mmAmplatzer MuscularVSD Occluder
If it doesn’t –crosCsonsider balloon aortic transthoracic (tratanmsappoincaadl eor transaortic) access Your guidewire tip may not be conducting current: Pull Amplatz–erCcoanbsliedetro(CA-TAVReligibility)
2+
AorticCa/thickening/ectasia
Targetentrysitelumbarvertebra
Orthogonalprojection Caval-aorticdistanceX-Y Interposedstructures Nearbystructures Cavallumendiameter Aorticlumendiameter(+3/0/-1.2cm)
Power inject artery below SMA (10ml for 1 sec) Hand-inject vein simultaneously
STEP #3 - Prepare Crossing System
0.014” guidewire
0.014” to 0.035” wire
convertor
microcatheter, to deliver
later Lunderquist
(or)
• 2x20mm Advance Micro 14 tibial balloon inside a
CXI support catheter
ELECTROSURGERY
• No short circuits
•
Ground pad without
经腔静脉-主动脉入路TAVR
手术入路
Transaortic 3.6%
Subclavian 0.3%
Transapical
33.5%
Transfemoral 62.6%
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。
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TAVR
Procedure schematic
Proposed physiology
A: Cross from IVC through calcium-free window into prepositioned aortic snare B: Exchange for rigid guidewire C: Deliver sheath and TAVR D: Close with nitinol occluder
through tract into cava ▪ Pull Amplatzer cable to reach
cava, then push cable to re-form
venous side
STEP #10 – Completion Angiography
2x20mm Advance Micro Retroperitoneal space pressure is higher than vein. Historical-Intrathoracic Transapical
Favorable;Uncertain;Unfavorable Aorticcalciumgrade2
MidBodyL3(L3.0) AP 6mm(including1mmnon-calcifiedatheroma)
none Bowelanteriortotarget
23mm 15mm/16mm/14mm 12mm 75mm
8/6AmplatzerDuct Occludergeneration1
STEP # 9 - Closure
▪ Place buddy wire ▪ Insert deflectable sheath ▪ Passively expose aortic disc ▪ Position pigtail ▪ Withdraw and deflect sheath to
▪ NIH sponsored - site monitoring, DSMB oversight, CEC adjudication of primary and secondary endpoints
crossing point
Interposedstructures
Side arm up for
Simultaneous Aortic2a0n1d3IV年C A7n月gio3g日rap，hy在美国底特律Henry Ford医院，Dr. Lederman和Dr.
long tunnel,
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
crossing point
▪ Withdraw TAVI sheath into IVC ▪ Advance pigtail cephalad & test ▪ Retract disc onto R aortic wall ▪ Straighten Agilis during withdrawal
0.035”
microcatheter
Electrosurge
ry pencil
Back end of
0.014”
guidewire
COAXIAL
• Confienza amputated tip,
inside a
•
Piggyback wire convertor,
inside a
•
Navicross braided
Disconnected, charred, short-circuited, etc.
Not like this
Like this
13
STEP #6 - Snaring and Advancingasp ic
position
Advance in tandem with traversal wire & wire convertor
Caval-aortic fistula + “cruciform” extra-aortic
contrast
Of 79 cases
N=5
Extravasation
(Endograft 7 hrs. later)
残余动静脉分流的转归
Transcaval Access for TAVR IDE Registry
interposed metallic hips &
pacemakers
•
50W “cutting” mode
Advance Micro 14 ID compatible
0.035” CXI support catheter
STEP #4 –
Align Guiding Catheter in Orthogonal Views
Iliac-aortic conduits
Transcaval
8/6AmplatzerDuct
Cincinnati, OH
Withdraw TAVI sheath into IVC
Electrosurge
Transfemoral
Instituto Dante Pazzanese de
Electrosurge
Retroperitoneal space pressure is higher than vein.
Aortic bleeding decompresses through a hole in IVC into vasculature
STEP #1 –
Obtain CT-based Treatment Plan
University of Virginia
非股▪动脉入R路ep的ea其t a他n入gi路ogram
RCIA5.2mm,LCIA3.0mm 24cm 15x20mmtargetwindow Yes MChenread.2014-xx-xx
Lederman, JACC Imaging, 2014
Marcus Chen, NHLBI Core Lab
STEP #2 –
Simultaneous Aortic and IVC Angiography
Targetdistanceaboveaorto-iliacbifurcation
TargetdistancebelowRrenal artery Endograftbailoutlimbaccess CFVtotargetcenterlinedistance Caveat&Comments
LiesflatontheCTscanner? ReviewersNHLBI
CPiagrgil▪yiobnacMkRetdiepivcaileCwenatnergio before No short crierclueiatsse cable and buddy
Advance sheath in one step
Historical-wInitrraethoracic
DAoertrti▪ociltuMmeeIdfnidcbiaallemCeeedtneitrne(+rg3/0/-1.
Patterns of Completion Angiography
Type 0
Type 1
Type 2
Type 3
N=16
Complete occlusion
Most common pattern
N=16
N=42
Caval-aortic fistula with
long tunnel,
no extravasation
Only attempt for about 1sec
If it doesn’t cross
▪ Your target may be too calcific: re-position or reorient
▪ Your guidewire tip may not be conducting current:
Repeat angiogram
temporary LV assist device placement for cardiogenic
no extravasation 经腔静脉-主动脉路径TAVR
Transaortic 3.
Caveat&Comments
Transaortic 3.
Advance pigtail cephalad & test
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
Historical-Intrathoracic
Newer-Extrathoracic
Carotid direct
aortic
subclavian/
Percutaneous axillary
transapical
Wire tip
In lateral projection, fine-tune orientation away from bowel or
calcium as needed
Piggyback tip
Navicross tip
Duodenum Ao
IVC
Different patient
STEP #5 - Crossing
STEP #7 - Sheath Insertion
Advance sheath in one step Side arm up for
Edwards eSheath
Hemostasis is universal
STEP #8 – Select a Closure Device
Current Closure Device Algorithm
Sheath Aorto-cavaltract length≤7mm
Aorto-cavaltract length>7mm
>18FrID 8mmAmplatzer MuscularVSD Occluder
10/8AmplatzerDuct Occludergeneration1
<=18FrID 6mmAmplatzer MuscularVSD Occluder
If it doesn’t –crosCsonsider balloon aortic transthoracic (tratanmsappoincaadl eor transaortic) access Your guidewire tip may not be conducting current: Pull Amplatz–erCcoanbsliedetro(CA-TAVReligibility)
2+
AorticCa/thickening/ectasia
Targetentrysitelumbarvertebra
Orthogonalprojection Caval-aorticdistanceX-Y Interposedstructures Nearbystructures Cavallumendiameter Aorticlumendiameter(+3/0/-1.2cm)
Power inject artery below SMA (10ml for 1 sec) Hand-inject vein simultaneously
STEP #3 - Prepare Crossing System
0.014” guidewire
0.014” to 0.035” wire
convertor
microcatheter, to deliver
later Lunderquist
(or)
• 2x20mm Advance Micro 14 tibial balloon inside a
CXI support catheter
ELECTROSURGERY
• No short circuits
•
Ground pad without
经腔静脉-主动脉入路TAVR
手术入路
Transaortic 3.6%
Subclavian 0.3%
Transapical
33.5%
Transfemoral 62.6%
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。
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TAVR
Procedure schematic
Proposed physiology
A: Cross from IVC through calcium-free window into prepositioned aortic snare B: Exchange for rigid guidewire C: Deliver sheath and TAVR D: Close with nitinol occluder
through tract into cava ▪ Pull Amplatzer cable to reach
cava, then push cable to re-form
venous side
STEP #10 – Completion Angiography
2x20mm Advance Micro Retroperitoneal space pressure is higher than vein. Historical-Intrathoracic Transapical
Favorable;Uncertain;Unfavorable Aorticcalciumgrade2
MidBodyL3(L3.0) AP 6mm(including1mmnon-calcifiedatheroma)
none Bowelanteriortotarget
23mm 15mm/16mm/14mm 12mm 75mm
8/6AmplatzerDuct Occludergeneration1
STEP # 9 - Closure
▪ Place buddy wire ▪ Insert deflectable sheath ▪ Passively expose aortic disc ▪ Position pigtail ▪ Withdraw and deflect sheath to
▪ NIH sponsored - site monitoring, DSMB oversight, CEC adjudication of primary and secondary endpoints
crossing point
Interposedstructures
Side arm up for
Simultaneous Aortic2a0n1d3IV年C A7n月gio3g日rap，hy在美国底特律Henry Ford医院，Dr. Lederman和Dr.
long tunnel,
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
crossing point
▪ Withdraw TAVI sheath into IVC ▪ Advance pigtail cephalad & test ▪ Retract disc onto R aortic wall ▪ Straighten Agilis during withdrawal
0.035”
microcatheter
Electrosurge
ry pencil
Back end of
0.014”
guidewire
COAXIAL
• Confienza amputated tip,
inside a
•
Piggyback wire convertor,
inside a
•
Navicross braided
Disconnected, charred, short-circuited, etc.
Not like this
Like this
13
STEP #6 - Snaring and Advancingasp ic
position
Advance in tandem with traversal wire & wire convertor
Caval-aortic fistula + “cruciform” extra-aortic
contrast
Of 79 cases
N=5
Extravasation
(Endograft 7 hrs. later)
残余动静脉分流的转归
Transcaval Access for TAVR IDE Registry
interposed metallic hips &
pacemakers
•
50W “cutting” mode
Advance Micro 14 ID compatible
0.035” CXI support catheter
STEP #4 –
Align Guiding Catheter in Orthogonal Views
Iliac-aortic conduits
Transcaval
8/6AmplatzerDuct
Cincinnati, OH
Withdraw TAVI sheath into IVC
Electrosurge
Transfemoral
Instituto Dante Pazzanese de
Electrosurge
Retroperitoneal space pressure is higher than vein.
Aortic bleeding decompresses through a hole in IVC into vasculature
STEP #1 –
Obtain CT-based Treatment Plan