title: Anatomic Suitability for Transcaval Access Based on Computed Tomography.
abstract: Transcaval access has been used successfully for over 200 transcatheter aortic valve replacements, large-bore percutaneous left ventricular assist devices, and thoracic endovascular aortic aneurysm repairs. This review teaches how to plan transcaval access and closure based on computed tomography. The main planning goals are to: 1) identify calcium-free crossing targets in the abdominal aorta along with optimal fluoroscopic projection angles and level with respect to lumbar vertebrae; 2) identify obstacles such as interposed bowel or pedunculated aortic atheroma; 3) plan covered stent bailout; and 4) identify jeopardized vascular branches such as renal arteries that might be obstructed by bailout covered stents if employed. The aorta and inferior vena cava are segmented (sculpted) using an image reconstruction workstation and crossing targets are highlighted. Important measurements such as aortic lumen diameter and target distance from renal arteries, aortoiliac bifurcation, and right femoral vein puncture site are reported to assist the operator. The proposed classification for transcaval feasibility has been revised, making some previously unfavorable candidates now feasible or favorable based on procedural success to date. Transcaval access allows percutaneous introduction of large devices into the aorta despite small or diseased iliofemoral arteries. By following these simplified procedures, both operators and imaging specialists can easily prepare comprehensive treatment plans.
authors.affiliation: Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland. Electronic address: lederman@nih.gov.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Lederman
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Adam B
authors.initials: AB
authors.lastname: Greenbaum
authors.affiliation: Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Toby
authors.initials: T
authors.lastname: Rogers
authors.affiliation: Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Jaffar M
authors.initials: JM
authors.lastname: Khan
authors.affiliation: Edwards Lifesciences, Irvine, California.
authors.forename: Melissa
authors.initials: M
authors.lastname: Fusari
authors.affiliation: Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Marcus Y
authors.initials: MY
authors.lastname: Chen
mesh_terms: D059925:Anatomic Landmarks; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging*; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000601:surgery; D001027:Aortography / Q000379:methods*; D000072226:Computed Tomography Angiography; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods; D006353:Heart-Assist Devices; D006801:Humans; D018579:Patient Selection; D010690:Phlebography / Q000379:methods*; D011237:Predictive Value of Tests; D019919:Prosthesis Implantation / Q000295:instrumentation / Q000379:methods; D012077:Renal Artery / Q000000981:diagnostic imaging; D015607:Stents; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods; D061205:Vascular Calcification / Q000000981:diagnostic imaging; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging*
keywords: aorto-caval; caval-aortic; computed tomography; structural heart disease; transcatheter aortic valve replacement; transcatheter electrosurgery; transcaval