经腔静脉_主动脉入路TAVR

Center Henry Ford Hospital1
Detroit, MI
Total 79
IDE 37
Angiografia de Occidente2
Cali, Colombia
15
Detroit Medical Center
Detroit, MI
3
Spectrum Health
Grand Rapids, MI
Disconnected, charred, short-circuited, etc. Only attempt for about 1sec
STEP #6 - Snaring and Advancingasp ic position
Advance in tandem with traversal wire & wire convertor
23mm
Aorticlumendiameter(+3/0/-1.2cm)
15mm/16mm/14mm
Targetdistanceaboveaorto-iliacbifurcation
12mm
TargetdistancebelowRrenal artery
75mm
Endograftbailoutlimbaccess
RCIA5.2mm,LCIA3.0mm
CFVtotargetcenterlinedistance
24cm
Caveat&Comments
15x20mmtargetwindow
LiesflatontheCTscanner?
Yes
ReviewersNHLBI
MChenread.2014-xx-xx
STEP #1 – Obtain CT-based Treatment Plan
N=42 Caval-aortic fistula + "cruciform" extra-aortic contrast
N=5 Extravasation <Endograft 7 hrs. later>
Type 0
Type 1
Type 2
Type 3
Most common pattern
13
Like this
Not like this
STEP #5 - Crossing
Your target may be too calcific: re-position or re- orient Your guidewire tip may not be conducting current:
STEP #10 – Completion Angiography
Patterns of Completion Angiography
N=16 Complete occlusion
N=16 Caval-aortic fistula with long tunnel, no extravasation
0.035 CXI support catheter ELECTROSURGERY
• •
No short circuits Ground pad without interposed metallic hips &
pacemakers
•
50W "cutting" mode
Advance Micro 14 2.9F ID compatible
经腔静脉-主动脉路径TAVR
Procedure schematic 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
STEP #3 - Prepare Crossing System
0.014" guidewire 0.014" to 0.035" wire convertor
0.035" microcatheter
Back end of 0.014" guidewire
Electrosurge
ry
COAXIAL • Confienza amputated tip,
STEP #8 – Select a Closure Device
Current Closure Device Algorithm
Place buddy wire Insert deflectable sheath Passively expose aortic disc Position pigtail Withdraw and deflect sheath to crossing point Withdraw TAVI sheath into IVC Advance pigtail cephalad & test Retract disc onto R aortic wall Straighten Agilis during withdrawal through tract into cava Pull Amplatzer cable to reach cava, then push cable to re-form venous side
2
1
IDE
Center German Heart Center
Munich, GE
Total 3
Wake Forest Baptist Health
Winston Salem, NC
经腔静脉-主moral 62.6%
手术入路 Transaortic 3.6% Subclavian 0.3% 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.
Proposed physiology Retroperitoneal space pressure is higher than vein. Aortic bleeding decompresses through a hole in IVC into vasculature
0.035" CXI support catheter
STEP #4 – Align Guiding Catheter in Orthogonal Views
If it doesn’t cross
Of 79 cases
残余动静脉分流的转归
Transcaval Access for TAVR IDE Registry
NIH sponsored - site monitoring, DSMB oversight, CEC adjudication of primary and secondary endpoints 20 sites, 100 patient, nonrandomized prospective registry; concomitant retrospective registry of all known cases Primary endpoint: "device success" successful transcaval access and closure without death related to access or closure Enrollment began 10/2014 99/100 patients enrolled
1
Emory University
Atlanta, GA
25
16
University of Utah
Salt Lake City, UT
2
Oklahoma Heart
Tulsa, OK
11
8
Brigham and Women’s
Boston, MA
1
Columbia University
New York, NY
Recommendation(CA-TAVReligibility)
Favorable;Uncertain;Unfavorable
2+ AorticCa/thickening/ectasia
Aorticcalciumgrade2
Targetentrysitelumbarvertebra
MidBodyL3(L3.0)
非股动脉入路的其他入路
Carotid direct
aortic transapical Iliac-aortic conduits Transcaval
subclavian/ Percutaneous axillary
Newer-Extrathoracic
• •
inside a Piggyback wire convertor, inside a Navicross braided 0.035 microcatheter, to deliver later Lunderquist <or>
•
2x20mm Advance Micro 14 tibial balloon inside a
STEP #7 - Sheath Insertion
Hemostasis is universal
Side arm up for
Edwards eSheath
Advance sheath in one step
Sheath
>18FrID
<=18FrID
Aorto-cavaltract length≤7mm
Orthogonalprojection
AP
Caval-aorticdistanceX-Y
6mm(including1mmnon-calcifiedatheroma)
Interposedstructures
none
Nearbystructures
Bowelanteriortotarget
Cavallumendiameter
8mmAmplatzer MuscularVSD Occluder
6mmAmplatzer MuscularVSD Occluder
Aorto-cavaltract length>7mm
10/8AmplatzerDuct Occludergeneration1
8/6AmplatzerDuct Occludergeneration1
Historical-Intrathoracic
20XX7月3日,在美国底特律Henry Ford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.
STEP # 9 - Closure
Review angio before release cable and buddy wire If bleeding – Consider balloon aortic tamponade – Consider endograft Close venous access site and wait 10 minutes Repeat angiogram
Lederman, JACC Imaging, 2014 Marcus Chen, NHLBI Core Lab
STEP #2 – Simultaneous Aortic and IVC Angiography
Power inject artery below SMA <10ml for 1 sec> Hand-inject vein simultaneously