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vascular complication 20110902summitmd.com/pdf/pdf/1859.pdf · Vascular Complication Won-Jang Kim,...
Transcript of vascular complication 20110902summitmd.com/pdf/pdf/1859.pdf · Vascular Complication Won-Jang Kim,...
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Prevention, Prediction, and Treatment of
Vascular Complication
Won-Jang Kim, MD, PhDClinical Assistant Professor of Medicine, Heart Institute,
Asan Medical Center, Seoul, Korea
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For Successful TAVI,There are several factors.
Among them, vascular manuplation is the beginning and end of successful procedure
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82/F, 70kg/153cmChief complaint Chief complaint
DOE NYHA III
CoCo--morbiditymorbidityPCI at LAD, RCA & LCX (2009)HypertensionChronic lung disease (asthma)History of Stroke
Lab : Cr Lab : Cr 0.8 mg/dL
Logistic Euroscore : 29.54 %
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Aortic valve area: 0.6 cm2
Vmax: 3.9 m/secMax gradient: 69 mmHgMean gradient: 47 mmHg
Annulus: 21 mmEF: 62%TR Vmax = 34 mmHg
Severe Degenerative Aortic Stenosis
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CT AngiographyCT Angiography
Adequate vessel tortuosity
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Vessel Size on CT scanVessel Size on CT scanRight Left
7.77 mm
7.46 mm
7.26 mm
7.62 mm
7.28 mm
6.79 mm
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Aorto-iliac angiogramAorto-iliac angiogram
8.4 mm
8.3 mm9.7 mm
7.9 mm
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Retroflex 1EdwardsEdwards--SAPIEN THVSAPIEN THV
23mm23mmvalve sizesvalve sizes
22F22Fsheath sizessheath sizes
Edwards SAPIEN™
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ProcedureProcedure
• Rt. femoral artery cut-downwith 14 Fr sheath
• Lt. femoral vein puncture & pacing wire into the RV
• Check the rapid pacing (200 bpm)• Preparing Edward valve 23 mm
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Three cusps in same plane : RAO 0 CAUD 0
AortogramAortogram
Slightly LAO cranial or caudal
3 sinuses are visualized on 1 single line - perpendicularity
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Stepwise Dilation (16-25Fr)22Fr Sheath Insertion
Stepwise Dilation (16-25Fr)22Fr Sheath Insertion
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Start the Procedure, 22FStart the Procedure, 22FRt. femoral artery approach
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Crossing the Aortic Valve Crossing the Aortic Valve
6Fr Lt. Amplatz catheter with 0.035” straight guidewirefor cross the aortic valve (40’ LAO view)
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Preshaping (J-shaped) the 0.035/260cm extrastiff guidewire advanced into the LV
Pre-shaping Extrastiff Guidewire
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NuMed Z-Med II 20 mm balloon
Pre-dilatation Ballooningunder rapid pacing
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23mm Edward valve
Advanced RetroFlex-1 System
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Advanced RetroFlex-1 System
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The Edward valve crossed the native aortic valveWithdrawal of the Flex catheter
Main Procedure
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Valve Positioning under the TEE Guidance
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During deployment, valve embolizedcranial due to loss of capture
25mm
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Embolized valve was deployed at descending aorta
Embolized valve was deployed at descending aorta
We tried Valve-in-Valve again…We tried Valve-in-Valve again…
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NuMed Z-Med II 20 mm balloon
Pre-dilatation BallooningAgain
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2nd Valve positioning2nd Valve positioning
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2nd Valve Deployment2nd Valve Deployment
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Post-Deployment AortogramPost-Deployment Aortogram
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Immediate after Valve Deployment TEE
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Embolic Edwards Valve was repositioned at descending aorta
(TEE)
Embolic Edwards Valve was repositioned at descending aorta
(TEE)
Closed Valve leaflet Opened Valve leaflet
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Successful Valve-in-Valve,
We have some difficulty inretrieval of sheath.
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Balloon occlusion, emergent surgical repair
During keep removing, sudden hemodynamic collapse developed
During keep removing, sudden hemodynamic collapse developed
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Vascular OperationVascular Operation
Removed sheath
Ruptured iliac artery
Common iliac artery ligation with Femoral-Femoral bypass graft surgery
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Minimal paravalvular leakageAV Vmax = 2.7 m/smean pressure gradient = 16 mmHg
After surgery, patient was fully recovered. F/U Echocardiography
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Vascular ComplicationsPotential risk factors
Vascular ComplicationsVascular ComplicationsPotential risk factorsPotential risk factors
•• Patient relatedPatient related-- Vessel Vessel SizeSize-- CalcificationCalcification-- TortuosityTortuosity-- Vessel stenosisVessel stenosis-- PlaquePlaque
•• Technique/operator relatedTechnique/operator related-- Aggressive manipulationAggressive manipulation-- Inaccurate calibration and Inaccurate calibration and
measurementsmeasurements-- Poor controlPoor control-- Prolonged procedural timeProlonged procedural time
•• Device relatedDevice related-- TAVI systemTAVI system-- SheathSheath-- Guide wiresGuide wires-- BalloonBalloon-- Closure device Closure device
•• Patient relatedPatient related•• Vessel Vessel SizeSize•• CalcificationCalcification•• TortuosityTortuosity•• Vessel stenosisVessel stenosis•• PlaquePlaque
•• Technique/operator relatedTechnique/operator related•• Aggressive manipulationAggressive manipulation•• Inaccurate calibration and Inaccurate calibration and
measurementsmeasurements•• Poor controlPoor control•• Prolonged procedural timeProlonged procedural time
Device relatedDevice relatedTAVI systemTAVI systemSheathSheathGuide wiresGuide wiresBalloonBalloonClosure device Closure device
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After initial 5 cases,
We changed the approach technique,
We used the RF-3 system
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Femoral Artery Puncture under Fluoroscopic Guidance
Femoral Artery Puncture under Fluoroscopic Guidance
Anteriorsuperior
iliac spineInguinal
skin crease
Inguinalligament
Femoralhead
Commonfemoralartery
Superficialfemoralartery
Profundafemoralartery
Puncture site, CFA
Initial Ileofemoral Aortography
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No need to surgical exposure
Before Procedure After Procedure
Percutaneous Closure Proglide
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Evolution of the Edwards Transfemoral Delivery System
Evolution of the Edwards Transfemoral Delivery System
Product Design Updates• 18F Profile• Enhanced distal end• Designed for Valve Alignment
RetroFlex 3 System• Balloon-expandable
transcatheter valve delivery• Steerable catheter• Tapered distal end• Accurate valve deployment
• Balloon-expandable transcatheter valve delivery
• Steerable catheter
RetroFlex System• Balloon-expandable transcatheter valve delivery
• Steerable catheter• Tapered distal end• Accurate valve deployment
NovaFlex System
22F, 24F 18F, 19F
Getting Smaller in SizeGetting Smaller in Size
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Baseline Angiography & CT Baseline Angiography & CT
Made by Adw 4.5, GE healthcare system
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Difficulty in Advancement Severe calcific small vessel
Difficulty in Advancement Severe calcific small vessel
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Vascular ComplicationsPotential risk factors
Vascular ComplicationsVascular ComplicationsPotential risk factorsPotential risk factors
•• Patient relatedPatient related•• Vessel Vessel SizeSize•• CalcificationCalcification•• TortuosityTortuosity•• Vessel stenosisVessel stenosis•• PlaquePlaque
•• Technique/operator relatedTechnique/operator related•• Aggressive manipulationAggressive manipulation•• Inaccurate calibration and Inaccurate calibration and
measurementsmeasurements•• Poor controlPoor control•• Prolonged procedural timeProlonged procedural time
Device relatedDevice relatedTAVI systemTAVI systemSheathSheathGuide wiresGuide wiresBalloonBalloonClosure device Closure device
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CT – Ileofemoral Artery CT – Ileofemoral Artery
Size Measure, Calcium distribution, Tortuosity,,,
Made by Adw 4.5, GE healthcare system
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Angiography Angiography
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Access Routes For TAVRAccess Routes For TAVR
Femoral- Edwards SAPIEN
- CoreValve Trans-apical- Edwards SAPIEN
Axillary- CoreValveTrans-Aortic
- CoreValve
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Lessions from Our CasesVascular Problem
Lessions from Our CasesVascular Problem
• Baseline evaluation of ileofemoral arterial system is very important : CT, Angiogram
• Adequate access site : TF, TA• Prompt recognition and diagnosis will save
lives• Ensure all back-up equipment is available
in the room• With advance in device technology,
vascular problem will decrease in the future