經(jīng)腔靜脈-主動脈入路TAVR5/9/20241經(jīng)腔靜脈主動脈入路TAVR33.5%Transfemoral

62.6%

手術(shù)入路

Transaortic

3.6%

Subclavian

0.3%Transapical5/9/20242經(jīng)腔靜脈主動脈入路TAVR手術(shù)入路1、股動脈入路常常需要18F-22F鞘管，術(shù)后易出現(xiàn)血管并發(fā)癥，且髂動脈嚴重鈣化迂曲、血管直徑過小或者合并外周動脈疾病者存在禁忌。2、包括經(jīng)心尖在內(nèi)的經(jīng)胸腔入路，術(shù)后恢復(fù)慢，且伴隨更多的術(shù)后并發(fā)癥。5/9/20243經(jīng)腔靜脈主動脈入路TAVR非股動脈入路的其他入路Carotid

direct

aortic

transapical

Iliac-aortic

conduitsTranscavalsubclavian/Percutaneous

axillaryNewer-ExtrathoracicHistorical-Intrathoracic5/9/20244經(jīng)腔靜脈主動脈入路TAVR5/9/20245經(jīng)腔靜脈主動脈入路TAVR2013年7月3日，在美國底特律HenryFord醫(yī)院，Dr.Lederman和Dr.Greenbaum以及他們的同事們，采用該術(shù)式為一位80歲女性患者成功進行了TAVR。術(shù)前，其他介入路徑，如經(jīng)股動脈、經(jīng)心尖、經(jīng)鎖骨下等在這位患者身上均嘗試失敗，因此手術(shù)團隊決定實施首例人類腔靜脈-主動脈路徑TAVR手術(shù)，手術(shù)獲得了成功。5/9/20246經(jīng)腔靜脈主動脈入路TAVR經(jīng)腔靜脈-主動脈路徑TAVR

ProcedureschematicA:CrossfromIVCthroughcalcium-freewindowintoprepositionedaorticsnareB:ExchangeforrigidguidewireC:DeliversheathandTAVRD:Closewithnitinoloccluder

ProposedphysiologyRetroperitonealspacepressureishigherthanvein.AorticbleedingdecompressesthroughaholeinIVCintovasculature5/9/20247經(jīng)腔靜脈主動脈入路TAVRRecommendation(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

–Obtain

CT-based

Treatment

PlanLederman,

JACC

Imaging,

2014

Marcus

Chen,

NHLBI

Core

Lab5/9/20248經(jīng)腔靜脈主動脈入路TAVRSTEP#2–SimultaneousAorticandIVCAngiographyPower

inject

artery

below

SMA

(10ml

for

1

sec)Hand-inject

vein

simultaneously5/9/20249經(jīng)腔靜脈主動脈入路TAVRSTEP#3-PrepareCrossingSystem0.014”guidewire0.014”

to0.035”

wireconvertor0.035”microcatheterBack

end

of0.014”guidewireElectrosurge

rypencilCOAXIAL?

Confienza

amputated

tip,??inside

aPiggyback

wire

convertor,inside

aNavicross

braided

0.035microcatheter,

to

deliverlater

Lunderquist

(or)?2x20mm

Advance

Micro14

tibial

balloon

inside

a

0.035

CXI

support

catheterELECTROSURGERY??No

short

circuitsGround

pad

withoutinterposed

metallic

hips

&pacemakers?50W

“cutting”

modeAdvance

Micro

142.9F

ID

compatible0.035”

CXI

support

catheter5/9/202410經(jīng)腔靜脈主動脈入路TAVRAoIVCSTEP#4–AlignGuidingCatheterinOrthogonalViews

In

lateral

projection,

fine-tune

orientation

away

from

bowel

or

calcium

as

needed

Wire

tip

Piggyback

tip

DuodenumNavicross

tip

Different

patient5/9/202411經(jīng)腔靜脈主動脈入路TAVRIf

it

doesn’t

cross13Like

thisNot

like

thisSTEP#5-Crossing

Your

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

1sec5/9/202412經(jīng)腔靜脈主動脈入路TAVRSTEP#6-SnaringandAdvancingasp

ic

position

Advance

in

tandem

withtraversal

wire

&

wire

convertor5/9/202413經(jīng)腔靜脈主動脈入路TAVRSTEP#7-SheathInsertionHemostasis

is

universalSide

arm

up

forEdwards

eSheathAdvance

sheath

in

one

step5/9/202414經(jīng)腔靜脈主動脈入路TAVRSheath>18FrID<=18FrIDAorto-cavaltractlength≤7mm8mmAmplatzerMuscularVSDOccluder6mmAmplatzerMuscularVSDOccluderAorto-cavaltractlength>7mm10/8AmplatzerDuctOccludergeneration18/6AmplatzerDuctOccludergeneration1STEP#8–SelectaClosureDeviceCurrent

Closure

Device

Algorithm5/9/202415經(jīng)腔靜脈主動脈入路TAVR

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

Agilis

during

withdrawalthrough

tract

into

cavaPull

Amplatzer

cable

to

reachcava,

then

push

cable

to

re-formvenous

sideSTEP#9-Closure5/9/202416經(jīng)腔靜脈主動脈入路TAVR

Review

angio

beforerelease

cable

and

buddywireIf

bleeding

–

Consider

balloon

aortic

tamponade

–

Consider

endograftClose

venous

access

siteand

wait

10

minutesRepeat

angiogramSTEP#10–CompletionAngiography5/9/202417經(jīng)腔靜脈主動脈入路TAVRPatterns

of

Completion

Angiography

N=16Complete

occlusion

N=16Caval-aortic

fistula

with

long

tunnel,

no

extravasation

N=42

Caval-aortic

fistula

+“cruciform”

extra-aortic

contrast

N=5

Extravasation(Endograft

7

hrs.

later)Type

0Type

1Type

2Type

3

Mostcommon

patternOf

79

cases5/9/202418經(jīng)腔靜脈主動脈入路TAVR殘余動靜脈分流的轉(zhuǎn)歸5/9/202419經(jīng)腔靜脈主動脈入路TAVRTranscaval

Access

for

TAVR

IDE

Registry

NIH

sponsored

-

site

monitoring,

DSMB

oversight,

CEC

adjudication

ofprimary

and

secondary

endpoints

20

sites,

100

patient,

nonrandomized

prospective

registry;

concomitantretrospective

registry

of

all

known

cases

Primary

endpoint:

“device

success”

successful

transcaval

access

andclosure

without

death

related

to

access

or

closure

Enrollment

began

10/2014

99/100

patients

enrolled5/9/202420經(jīng)腔靜脈主動脈入路TAVRCenterHenry

Ford

Hospital1Detroit,

MITotal

79IDE

37Angiografia

de

Occidente2Cali,

Colombia15Detroit

Medical

CenterDetroit,

MI3Spectrum

HealthGrand

Rapids,

MI1Emory

UniversityAtlanta,

GA2516University

of

UtahSalt

Lake

City,

UT2Oklahoma

HeartTulsa,

OK118Brigham

and

Women’sBoston,

MA1Columbia

UniversityNew

York,

NY21IDECenterGerman

Heart

CenterMunich,

GETotal

3Wake

Forest

Baptist

HealthWinston

Salem,

NC74Good

SamaritanCincinnati,

OH3Edward

HospitalNaperville,

IL54Cleveland

Clinic

FoundationCleveland,

OH3University

of

VirginiaCharlottesville,

VA71York

HospitalYork,

PA33Toledo

HospitalToledo,

OH31Vanderbilt

UniversityNashville,

TN53CenterSt.

Vincent’s

HospitalIndianapolis,

INTotal

2IDE

2Instituto

Dante

Pazzanese

deCardiologia,

Sao

Paulo,

BR1Terrebone

HospitalHouma,

LA21Lexington

Medical

CenterColombia,

SC76Washington

Hospital

CenterWashington,

DC11Ochsner

Medical

CenterNew

Orleans,

LA77London

Health

Sciences

CtrLondon,

ON1Carilion

Medical

CenterRoanoke,

VA22Evanston

HospitalChicago,

IL22Total21499Worldwide

Transcaval

TAVI

Experience

Status

as

of

2016Bold:

independently

performing5/9/202421經(jīng)腔靜脈主動脈入路TAVRConclusions:TranscavalTAVR?TranscavalaccessenabledTAVRinpatientsineligiblefor

transfemoralaccessandathighorprohibitiveriskof

transthoracic(transapicalortransaortic)access?Independently-adjudicatedbleedingandvascularcomplications

wereacceptableinthishighriskcohort.

–Comparedwithlower-riskpatientsinPARTNER-II,transcaval

bleedingwasgreaterthanfemoral-arterybutlessthan

transthoracicaccess?Transcavalaccessandclosureshouldbeinvestigatedinpatients

whootherwisemightundergotransthoracicaccess?Purpose-builtclosuredevicesareunderdevelopmentthatmay

simplifytheprocedureandreducebleeding5/9/202422經(jīng)腔靜脈主動脈入路TAVRTranscaval

TAVR

Feasible,

teachable,

has

now

been

applied

to

>200

pts

todate

but

should

be

planned