经腔静脉_主动脉入路TAVR.pptVIP

经腔静脉-主动脉入路TAVR 33.5% Transfemoral 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。 非股动脉入路的其他入路 Carotid direct aortic transapical Iliac-aortic conduits Transcaval subclavian/ Percutaneous axillary Newer-Extrathoracic Historical-Intrathoracic 2013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 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 Proposed physiology Retroperitoneal space pressure is higher than vein. Aortic bleeding decompresses through a hole in IVC into vasculature Recommendation(CA-TAVReligibility) Favorable;Uncertain;Unfavorable 2+ AorticCa/thickening/ectasia Aorticcalciumgrade2 Targetentrysitelumbarvertebra MidBodyL3(L3.0) Orthogonalprojection AP Caval-aorticdistanceX-Y 6mm(including1mmnon-calcifiedatheroma) Interposedstructures none Nearbystructures Bowelanteriortotarget Cavallumendiameter 23mm Aorticlumendiameter(+3/0/-1.2cm) 15mm/16mm/14mm Targetdistanceaboveaorto-iliacbifurcation 12mm TargetdistancebelowRrenal artery 75mm Endograftbailoutlimbaccess RCIA5.2mm,LCIA3.0mm CFVtotargetcenterlinedistance 24cm CaveatComments 15x20mmtargetwindow LiesflatontheCTscanner? Yes ReviewersNHLBI MChenread.2014-xx-xx STEP #1 – Obtain CT-based Treatment Plan 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 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 pencil COAXIAL • Confienza amputated tip, • • inside a Piggyback wire convert