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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3590_Библиотеки_им_академика_М_И_Перельмана
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A
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Common
Superficial f.a.
Profunda f.a.
C D
45°
Inferior epigastric a.
femoral
artery
B
E
Fig. 2.6 Contemporary femoral arterial access. (A) Hemostat to identify lower edge of femoral head.
(B) Confirm position of hemostat with fluoroscopy. (C) Ultrasound positioned to visualize common femoral
artery (f.a.). (D) Ultrasound visualization of common femoral artery (left) and common femoral artery bifurcation
into superficial and profunda (right). (E and F) Triangulation for needle entry. (G) Needle entry position (arrow)
and guidewire advancement assessed using fluoroscopy. (H) Femoral angiography. (Sandoval Y, Burke MN,
Lobo AS, et al. Contemporary arterial access in the cardiac catheterization laboratory. JACC Cardiovasc
Interv. 2017;10:2233–2241.)
F
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A B
Fig. 2.7 Confirm satisfactory needle entry site using fluoroscopy. (A) Advance guidewire a short distance and
then evaluate needle entry under fluoroscopy. (B) Under fluoroscopic guidance, assess needle entry point (ensure
that over femoral head), and, if access considered adequate, advance wire. If using micropuncture, micropuncture
wire should always be advanced under fluoroscopic guidance to avoid inadvertent wiring of side branches.
insufficiency exist and contrast avoidance is preferred) obtained to confirm appropriate access and
identify and exclude up-front any potential problems.
For the preidentified preferred femoral access route intended for TAVR delivery, preclosure
using suture-mediated devices (e.g., Perclose Proglide, Abbott Laboratories, Abbott Park, IL) is
performed, as described in Fig. 2.9.
of the procedure with the operator’s preferred closure device.
Fig. 2.8 Routine femoral angiography.
13
The non-TAVR femoral access site can be closed at the end
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Fig. 2.9 Percutaneous closure with two ProGlides. (A, B) Sutures are deployed at 10 and 2 o’clock positions.
(C) A 16F dilator is inserted. The regular J wire is exchanged for a stiffer wire (D), and the large sheath is inserted
under fluoroscopy (E). After implantation of the valve, the sheath is retrieved (F), and the sutures are tightened
(G). (H, I) The wire is removed if sufficient hemostasis is achieved, and the sutures are further tightened using the
knot pusher. (Toggweiler S, Leipsic J, Binder RK, et al. Management of vascular access in transcatheter aortic
valve replacement: part 1: Basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv.
2013;6[7]:643–653, Figure 5.)
After TAVR, iliofemoral angiography from the ipsilateral or contralateral side should be
considered to identify any potential complications (e.g., large dissection, perforation, etc.) that
can occur after removal of the large sheath.
Complications: Preparation
Anticipating the potential for vascular complications, several strategies have been described to
facilitate the management of such complications, should they occur.
the non-TAVR femoral access site to advance a left internal mammary artery (LIMA) catheter
and a 0.035-mm glide wire to access the opposite iliofemoral system and then place a 0.018-mm
“safety” wire that allows access to the contralateral system (e.g., to allow for advancement of
peripheral balloons if required for hemostasis) should complications occur in the TAVR-access
15
site.
This approach, however, has been reported to have occasional disadvantages, such as wire
capture by the arteriotomy site closure device sutures or challenges in cases of hostile aortic
bifurcation due to angulation or calcification or severe calcific vascular diseases.
approaches addressing the same concept have been reported—for example, using a left radial
access approach or ipsilateral wiring only by accessing the superficial femoral artery below the
TAVR-access site.
14
2
2,14,15
One strategy is to use
14
Alternative
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Complications: Management
The most frequent major vascular complications reported to occur are (1) vascular dissection
(63%), (2) perforation (31%), and (3) access-site hematoma (23%).
dissection, treatment depends on the extent and hemodynamic relevance of such, with management focused on prolonged balloon inflation and stenting (self-expanding or balloon-expandable)
reserved for large dissections, in which case, temporary anticoagulation and subsequent use of
dual-antiplatelet therapy are recommended to prevent stent thrombosis.
foration, management can be surgical or percutaneous; if the latter, covered stents are often
2
needed.
As with any vascular perforation, hemostasis and bleeding control are key, for which
reason a balloon should be advanced immediately to achieve such—hence, the rationale for some
operators to have “safety” bailout wires in place. Management of vascular complications after
TAVR is described in Chapter 13.
16
For iliofemoral
2
For patients with per-
Summary and Take-Home Messages
n
Iliofemoral arterial vascular complications are common after large-bore percutaneous
access, which is most commonly required for TAVR.
n
Procedural planning, including preprocedural MDCT to guide access-site selection and
vascular access using contemporary techniques, including ultrasound guidance, is recommended to reduce incidence of vascular complications.
n
Fluoroscopic imaging of vascular access sites at the end of the procedure allows early
identification of any vascular complications.
References
1. Sandoval Y, Burke MN, Lobo AS, et al. Contemporary arterial access in the cardiac catheterization
laboratory. JACC Cardiovasc Interv. 2017;10:2233-2241.
2. Toggweiler S, Leipsic J, Binder RK, et al. Management of vascular access in transcatheter aortic valve
replacement: Part 2: Vascular complications. JACC Cardiovasc Interv. 2013;6:767-776.
3. Hayashida, Lefévre T, Chevalier B, et al. Transfemoral aortic valve implantation new criteria to predict
vascular complications. JACC Cardiovasc Interv. 2011;4:851-858.
4. Toggweiler S, Gurvitch R, Leipsic J, et al. Percutaneous aortic valve replacement: Vascular outcomes with
a fully percutaneous procedure. J Am Coll Cardiol. 2012;59:113-118.
5. Barbanti M, Buccheri S, Rodes-Cabau J, et al. Transcatheter aortic valve replacement with new-
generation devices: A systematic review and meta-analysis. Int J Cardiol. 2017;245:83-89.
6. Paone G, Eng M, Kabbani LS, et al. Transcatheter aortic valve replacement: Comparing transfemoral,
transcarotid and transcaval access. Ann Thorac Surg. 2018;106:1105-1112. doi: 10.1016/j.athoracsur.
2018.04.029
7. Greenbaum AB, Babalioros VC, Chen MY, et al. Transcaval access and closure for transcatheter aortic
valve replacement: A prospective investigation. J Am Coll Cardiol. 2017;69:511-521.
8. Webb JG, Wood DA. Current status of transcatheter aortic valve replacement. J Am Coll Cardiol.
2012;60:483-492.
9. Holmes DR Jr, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on
transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59:1200-1254.
10. Achebanch S, Delgado V, Hausleiter J, Schoenhagen P, Min JK, Leipsic JA. SCCT expert consensus docu-
ment on computed tomography imaging before transcatheter aortic implantation (TAVI)/transcatheter
aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr. 2012;6:366-380.
11. Toggweiler S, Leipsic J, Binder RK, et al. Management of vascular access in transcatheter aortic valve
replacement: Part 1: Basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv.
2013;6:643-653.
2—ACCESS AND PITFALLS 21
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12. Seto AH, Abu-Fael MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femoral arterial
access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial).
JACC Cardiovasc Interv. 2010;3:751-758.
13. Don C, Holper EM. Percutaneous suture closure for TAVR. Cardiac Interv Today. 2014;September/
October:53-57.
14. Kaluski E, Khan SU, Sattur, S et al. Arteriotomy site complication during transcatheter aortic valve
replacement: Ipsilateral wire protection and bailout. Cardiovasc Revasc Med. 2018;19:724-730. doi: 10.1016/
j.carrev.2018.02.004
15. Ramlawi B, Anaya-Ayala JE, Reardon MJ. Transcatheter aortic valve replacement (TAVR): Access
planning and strategies. Methodist Debakey Cardiovasc J. 2012;8:22-25.
16. Généreux P, Webb JG, Svensson LG, et al. Vascular complications after transcatheter aortic valve
replacement: Insights from the PARTNER (Placement of AoRTic TraNscatherER Valve) Trial. J Am
Coll Cardiol. 2012;60:1043-1052.
e1
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Abstract: Vascular complications are common after large-bore percutaneous access, for which
reason contemporary, safe vascular access techniques should be routinely used. This chapter summarizes contemporary vascular access techniques, including procedural planning, adequate site
selection, and access using both ultrasound and fluoroscopic guidance, as well as strategies to
prepare and/or manage vascular complications.
Keywords: vascular access; ultrasound; vascular closure; vascular complications
CHAPTER 3
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Imaging for SHD Interventions
Jeremy J. Thaden Joseph F. Maalouf
Introduction
The field of transcatheter structural heart interventions has grown tremendously in recent years.
Because operators are not able to directly visualize the cardiac anatomy during percutaneous procedures, live imaging is a critical component of safely and successfully performing these procedures.
Interventional echocardiography has thus evolved in tandem with the growth of structural heart
procedures. Echocardiography has become an important part of preprocedural planning, procedural
guidance, and postprocedural assessment. Commonly performed procedures include transcatheter
aortic valve replacement (TAVR), transcatheter valve-in-valve implantation or valve-in-ring implantation, closure of paravalvular regurgitation (PVR), edge-to-edge mitral valve repair (TMVR),
and left atrial appendage occlusion (LAAO), among others. Intensive interest and ongoing trials are
currently evaluating transcatheter options to treat mitral regurgitation (MR) with transcatheter
mitral valve replacement (valve in native annulus) or alternative transcatheter mitral valve repair
devices, as well as new devices to treat tricuspid regurgitation. These new devices have the potential
to provide treatment options for patients deemed to have a high or prohibitive risk for conventional
open surgery.
GENERAL PRINCIPLES
A number of challenges are unique to interventional echocardiography that are not commonly
encountered in other areas of the echocardiography practice. Procedural success relies on the
echocardiographer’s ability to track catheters and devices in the heart to ensure safe passage and
avoid potential complications. This can be challenging due to movement of catheters related to
respiration, cardiac motion, and device manipulation by the operator. Furthermore, the devices
themselves commonly cause an element of acoustic shadowing, which can make it more challenging to visualize normal cardiac structures. Finally, devices and catheters often distort normal
cardiac anatomy, which can make it challenging to assess the procedural results. When threedimensional echocardiographic (3DE) guidance is required, blooming and other artifacts specific
to 3DE may make it difficult to distinguish between wires and catheters.
Effective communication among the procedural team is a critical component of procedural success and begins when the imager relays important preprocedural findings to the interventionalists.
A common language based on fixed spatial anatomic reference landmarks is essential for effective
communication. As the procedure begins, it is important that the echocardiographer be familiar
with the technical aspects of the procedure being performed, including the different types of catheters/sheaths/wires and dilators used, to anticipate the next steps and potential complications.
Effective procedural imaging incorporates a variety of imaging modes, including 2D, 3D,
color Doppler, and spectral Doppler imaging. Frequently, a multiparametric approach is necessary
for procedural success. Compared with two-dimensional echocardiography (2DE), 3DE provides
a panoramic view of anatomic structures from a single imaging window, which in turn provides
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contextual anatomic guidance during transcatheter interventions, but the temporal (frame rate)
and spatial resolutions are lower.
Transcatheter Aortic Valve Replacement
There is considerable practice variation in utilization of transthoracic vs. transesophageal echo-
cardiography (TEE) for TAVR periprocedural imaging in our current clinical practice, we utilize
TTE in the majority of TAVR cases, with TEE used where a good image cannot be attained with
TTE and for all transapical TAVRs. To effectively use TTE for TAVR guidance, one must have
adequate image quality to definitively assess for PVR and other relevant periprocedural complica-
tions. In cases where TTE quality is inadequate, there should ideally be the ability to convert to
TEE for more definitive assessment.
PREPROCEDURAL ECHOCARDIOGRAPHIC ASSESSMENT
TTE remains the workhorse for diagnosing aortic stenosis and quantifying the severity. Addi-
tionally, echocardiography is useful in defining the aortic anatomy (e.g., bicuspid vs. tricuspid),
quantifying biventricular systolic function and diastolic function, screening for pulmonary hyper-
tension and preexisting pericardial effusion, and evaluating for coexistent valve disease that could
affect patient management. 2DE imaging is also useful to screen for asymmetric or bulky calci-
fication, which can be problematic at the time of valve implantation. This requires the use of
orthogonal and off-axis views. Significant asymmetric valve calcification can increase the risk of
PVR postprocedure. Calcification that extends into the aortomitral continuity can also be prob-
lematic at the time of valve deployment and can increase the risk of subannular rupture. Strategies
for choice of valve to best address these anatomic findings are detailed in Chapters 8 and 9.
Frequently, the added depth perspective of 3DE can be helpful to visualize the extent and loca-
tion of subaortic annular calcification (Fig. 3.1).
At most institutions, cardiac computed tomography (CT) is the primary method to quantify
aortic annular size before valve implantation. Because of the irregular and frequently ellipsoid
shape of the aortic annulus, a single linear dimension of the aortic annulus may not accurately
represent the true annular area or perimeter. 3D imaging modalities are superior in quantifying
the aortic annular size and reducing the risk of PVR postprocedure. In experienced hands, 3D
Fig. 3.1 Pre-TAVR assessment of LVOT calcification. No significant subaortic annular calcification is noted
in the standard long-axis TEE view of a patient with aortic stenosis (A). Off-axis views, orthogonal views, and
frequently 3D echocardiography (B) are useful to better define subannular calcification (*) and risk for complications. Ao, Ascending aorta; LA, left atrium; LVOT, left ventricular outflow tract.
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TEE using multiplanar reconstruction is equivalent to CT in sizing the aortic annulus.
1,2
This
method can be utilized in situations where contrast administration is contraindicated, when the
CT is equivocal, or when the aortic annulus is on the cusp of two valve sizes (Fig. 3.2). With each
method, the aortic annular size is measured at midsystole at the nadir of the aortic valve leaflets.
2DE and 3D TEE can be useful to quantify the sinus of Valsalva and sinotubular junction dimensions, which, if small, also increase the risk of aortic root rupture and coronary artery obstruction.
Patients with coronary artery ostia in close proximity to the aortic annulus (,10 mm) are at
increased risk of coronary artery obstruction. Measurement of ostial heights above the annulus at
most institutions is done with CT preprocedurally, and this is detailed in later chapters. However,
ostial heights can also be measured with TEE. The left main coronary artery is typically seen best
Fig. 3.2 3D TEE with multiplanar reconstruction for aortic annular sizing. A 3D TEE volumetric dataset
can be opened in a quantitative package to perform multiplanar reconstruction for accurate aortic annular
measurements. Orthogonal long-axis planes are shown in panels A and C. The red lines depicted in panels
A and C are positioned at the level of the aortic annulus in two orthogonal long-axis views, which creates a
short-axis view of the aortic annulus for measurement of annular area, perimeter, and minimum/maximum
diameters (panel B). A surface-rendered 3D image of the aortic root is shown in panel D and provides additional context with respect to the three orthogonal planes (panels A, B, and C). Ann, Aortic annulus; Ao,
ascending aorta; LA, left atrium; LVOT, left ventricular outflow tract.
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Fig. 3.3 TEE measurement of coronary ostial height. Because of the spatial relationship between the ostium
of the left main coronary artery and the aortic annulus, the distance between the left main and aortic annulus is
not easily measured by 2D TEE. However, 3D TEE with multiplanar reconstruction allows one to realign the imag-
ing plane to include the ostium of the left main (A, red arrow) and the aortic annulus in the same plane, facilitating
measurement of the ostial “height” (A, yellow line). The ostium of the right coronary artery (B, yellow arrow) is
frequently well seen in the same plane as the aortic annulus by 2D TEE in a typical long-axis view, thereby facili-
tating this measurement by 2D TEE. AV, Aortic valve; Ao, ascending aorta; LVOT, left ventricular outflow tract.
with 3D TEE using multiplanar reconstruction. Because of its spatial relationship with the aortic
annulus, it is difficult to measure by 2D imaging (Fig. 3.3). The ostium of the right coronary
artery, in contrast, is typically best seen anteriorly in a midesophageal long-axis view of the aortic
root with a multiplane transducer angle of 120 to 150 degrees (see Fig. 3.3). A comprehensive
assessment of left ventricular function with attention to regional wall motion is important before
the procedure to serve as a baseline. Intraprocedural obstruction of the coronary arteries results
in significant changes in left ventricular function with regional abnormalities that fit a coronary
distribution.
Additional preprocedural considerations that must be documented include the presence and
size of any preexisting pericardial effusion. Acute procedure-related pericardial effusion is rare but
can occur most commonly due to laceration of the left ventricular myocardium by a guidewire or
the delivery system. Second, the presence and severity of MR. Overly deep implantation of a
transcatheter aortic valve can disrupt the normal motion of the anterior mitral leaflet and can
result in increased MR. And third, prominent subaortic septal hypertrophy because it can interfere with proper valve positioning and also predisposes to left ventricular outflow tract (LVOT)
obstruction after valve implantation.
POSTIMPLANTATION ECHOCARDIOGRAPHIC ASSESSMENT
The immediate post-TAVR implantation imaging is primarily focused on assessing prosthetic
valve function and potential procedure-related complications. These include the presence and
severity of PVR, mitral valve dysfunction, aortic root trauma/aortic dissection, abnormal prosthetic leaflet motion, valve thrombosis, and coronary artery obstruction. In patients with suboptimal or nondiagnostic TTE, TEE is needed.
After valve deployment, one of the most important first steps is to evaluate the TAVR valve
position and stent expansion. The TAVR valve position is best interrogated in echocardiographic
long-axis views (Fig. 3.4). A valve that is implanted too high may risk trauma to the sinotubular
junction or valve embolization, and there is increased risk of PVR. A valve that is implanted too
low increases the risk of PVR, procedure-related conduction disturbance, disruption of mitral
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