经腔静脉-主动脉入路TAVR.pptxVIP

经腔静脉-主动脉入路TAVR 手术入路 Transaortic 3.6% Subclavian 0.3%Transapical33.5%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。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-IntrathoracicNewer-ExtrathoracicCarotid directsubclavian/Percutaneous axillary aortic transapical Iliac-aortic conduitsTranscaval2013年7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。经腔静脉-主动脉路径TAVR Procedure schematicA: Cross from IVC through calcium-freewindow into prepositioned aortic snareB: Exchange for rigid guidewireC: Deliver sheath and TAVRD: Close with nitinol occluder Proposed physiologyRetroperitoneal space pressure is higher than vein.Aortic bleeding decompresses through a hole in IVCinto vasculatureSTEP #1 – Obtain CT-based Treatment PlanRecommendation(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,LCIA3.0mmCFVtotargetcenterlinedistance24cmCaveatComments15x20mmtargetwindowLiesflatontheCTscanner?YesReviewersNHLBIMChenread.2014-xx-xxLederman, JACC Imaging, 2014 Marcus Chen, NHLBI Core LabSTEP #2 – Simultaneous Aortic and IVC AngiographyPower inject artery below SMA (10ml for 1 sec)Hand-inject vein simultaneouslySTEP #3 - Prepare Crossing SystemCOAXIAL? Confienza amputated tip,Advance Micro 142.9F ID compatibleinside aPiggyback wire convertor,inside aNavicross braided 0.035microcatheter, to deliverlater Lunderquist (or)0.014”guidewire0.014” to0.035” wireconvertor???0.035”microcatheter2x20mm Advance Micro14 tibial balloon insi