Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Transseptal and Transapical
Antegrade Access for TEVAR
Sabine Wipper, MD, Christina Lohrenz, MD Tilo Kölbel, MD, PhD
University Heart Center University Hospital Eppendorf
Hamburg, Germany
Disclosures
Ü Research-grants, travelling, speaking-fees, IP with Cook.
Ü Research-grant, travelling, speaking-fees with Cordis
Background
Ü Treatment of choice for pathologies in the ascending aorta and the aortic arch is open surgical repair
Ü Severe comorbidities exclude some patients from surgical treatment
Ø Hypothesis:
Less invasive endovascular treatment options to avoid median stertotomy, aortic cross-clamping and cardiopulmonary bypass are necessary
Why Transcardiac Access?
Ü Access across aortic valve technically easier
Ü Lower damage risk of narrow or kinked aorto-iliac and femoral access vessels
Ü Access-profile nearly unlimited
Ü Short approach to target
Ü Better device control (straight orientation)
Ü Easy access to branches
Why Transcardiac Access?
Ü Easier stabilization against systolic jet
Ü Drainage of pericardial effusion
Ü Availability (cardiac-units)
Ü …
How to use it?
Ü Through & through wire access
Ü Introduction of main stent-graft
Ü Branch vessel access
Ü …
Transcardiac Access Routes
Ü Transseptal access
Ü Transapical access
Transapical Access
Ü Well established Access
Ü Standard access for TAVI
Ü Few casereports for TEVAR
Ü Open mini-thoracotomy, incision of pericardium
Ü ….
Transapical Access
Transapical Through & Through
Transapical TEVAR
Szeto et al 2010, Ann Thorac Surg 89: 616-8 MacDonald et al 2009, JVS 49: 759-62
Ü 67 year-old male
Ü Acute type A dissection
Ü Pericardial tamponade
Ü Severe comorbidities
Transapical TEVAR in Acute Type A Dissection
Transapical TEVAR in Acute Type A Dissection
Transapical TEVAR in Acute Type A Dissection
Transapical TEVAR in Acute Type A Dissection
Transapical TEVAR in Acute Type A Dissection
12h postop.
Transapical TEVAR in Acute Type A Dissection
6m postop.
Branch Vessel Access
Percutaneous Transapical TEVAR
Transapical Branchvessel-access
Perc. Transapical Closure
Transseptal Access
Pigtail katheter
EPU katheter
Transseptal sheath
Transseptal Access
Transseptal Access
Transseptal Access
Transseptal Puncture - History
Ü Joseph1997: Carotid artery stenting
Ü Dorros 2000: Stent-graft stabilization
Ü Cribier 2002: Aortic valve replacement
Joseph et al; Cathet Cardiovasc Diagn. 1997
Ü 65 year-old female
Ü 6,5cm TAA
Ü Multiple Kinks
Ü Morbidly obese
Transseptal Throughwire Access
Transseptal Throughwire Access
Transseptal Throughwire Access
Transseptal TEVAR
Transseptal Branchvessel-access
Critical Issues
Ü Transapical access: Ü Surgical exposure required Ü Pericardium to be crossed Ü ……….
Ü Transseptal access: Ü Strain to anterior mitral leaflet Ü Transient mitral reflux Ü ……….
Summary
Transcardiac access:
Ü Standard access for Aortic valve implantation
Ü Different access-routes through the heart
Ü Short distance, straight route, profile nearly unrestricted
Ü Relevance of transcardiac access yet to be defined
Thank you very much for your attention
Perc. Transapical Closure
Ü 32 patients, pred. paravalvular leak closure
Ü 5-12F sheaths
Ü Amplatzer-occludes
Jelnin et al. 2011JACC: Cardiovasc Interv 4:868-74
Perc. Transapical Closure
Jelnin et al. 2011JACC: Cardiovasc Interv 4:868-74
Transapical Through & Through
Ramponi et al 2011, JEVT 18: 350-4
Ü Single case report
Ü Mini-thorakotomy
Transapical TEVAR
Ü Few casereports
Ü Well established Access
Ü Cardiac axis