单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,精品课件,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品课件,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,精品课件,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,精品课件,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,精品课件,经腔静脉,-,主动脉入路,TAVR,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,33.5%Transfemoral手术入路,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。,手术入路1、股动脉入路常常需要18F-22F鞘管，术后易出现,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,非股动脉入路的其他入路Carotidaorticsubcl,经腔静脉-主动脉入路TAVR课件,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。,2013年7月3日，在美国底特律Henry Ford医院，D,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,经腔静脉-主动脉路径TAVRProcedure schem,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,Target,distanceaboveaorto-iliac,bifurcation,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,Lederman,JACC,Imaging,2014,Marcus,Chen,NHLBI,Core,Lab,Recommendation(CA-TAVReligibil,STEP#2,Simultaneous Aortic and IVC Angiography,Power,inject,artery,below,SMA,(10ml,for,1,sec),Hand-inject,vein,simultaneously,STEP#2 Power inject artery,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,convertor,inside,a,Navicross,braided,0.035,microcatheter,to,deliver,later,Lunderquist,(or),2x20mm,Advance,Micro,14,tibial,balloon,inside,a,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,0.035”,CXI,support,catheter,STEP#3-Prepare Crossing Sys,Ao,IVC,STEP#4,Align Guiding Catheter in Orthogonal Views,In,lateral,projection,fine-tune,orientation,away,from,bowel,or,calcium,as,needed,Wire,tip,Piggyback,tip,Duodenum,Navicross,tip,Different,patient,AoIVCSTEP#4 Navicross tip,If,it,doesnt,cross,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:,Disconnected,charred,short-circuited,etc.,Only,attempt,for,about,1sec,If it doesnt cross13Like this,STEP#6-Snaring and Advancing,asp,ic,position,Advance,in,tandem,with,traversal,wire,&,wire,convertor,STEP#6-Snaring and Advancin,STEP#7-Sheath Insertion,Hemostasis,is,universal,Side,arm,up,for,Edwards,eSheath,Advance,sheath,in,one,step,STEP#7-Sheath InsertionHemo,Sheath,18FrID,7mm,10/8AmplatzerDuct,Occludergeneration1,8/6AmplatzerDuct,Occludergeneration1,STEP#8 Select a Closure Device,Current,Closure,Device,Algorithm,Sheath18FrID200,pts,to,date,but,should,be,planned,carefully;,we,recommend,proctoring,Bleeding,and,transfusion,are,now,much,less,common,and,similar,to,transfemoral,TAVR,as,is,length,of,stay,NHLBI,sponsored,US,multicenter,IDE,using,Amplatzer,devices,is,99%,completed,Dedicated,closure,devices,to,achieve,immediate,hemostasis,are,in,development,Transcaval TAVR Feasible,t,Caval-Aortic,Access,Future Directions,Caval-aortic,access,has,now,been,utilized,for,TEVAR,temporary,LV,assist,device,placement,for,cardiogenic,shock,and,PCI,May,have,a,role,in,other,trans-catheter,treatments:,Large,devices,for,aortic,insufficiency?,Pediatric,uses?,Devices,yet,invented?,ledermannih.gov,Caval-Aortic Access Future,经腔静脉-主动脉入路TAVR课件,谢谢您的聆听,谢谢您的聆听,