Director Yu still felt how big Ruan Bin was just now!

Although the other party is very strong, there are some things that can be invincible without talent!

For example, now that he has seen the results of various examinations, he should have weighed it in his heart.

"I'm still ninety percent sure!" Ruan Bin said lightly.

"Shhh...... Are you sure?"

"Sure!"

"Then which path will you choose?" Director Yu squinted. He now feels obligated to talk to Ruan Bin about this patient's fatal surgical problem!

"Use the femoral artery retrograde puncture!" Ruan Bin thought for a moment.

"Femoral artery retrograde puncture, although this approach is currently a conventional approach, but combined with the current patient's situation, it has become the most difficult approach, right?" Director Yu frowned.

"The patient's chest wall echocardiogram shows an aortic valve area of 0.5 cm2, a mean pressure gradient of 86 mmHg, and a left ventricular ejection fraction of 64%. Transesophageal echocardiogram: aortic annulus diameter of 23.5 mm. Angiography showed mild calcification of the iliac and femoral arteries with good internal diameter. CT findings: distorted aorta, significant curvature of the distal aortic arch, and two torsions of the descending aorta!"

"If the surgery is to be performed, it is assumed that a transfemoral artery is chosen, and that a self-inflatable 29 mm stent is fed, but the stent is blocked from advancing in the distal plane of the aortic arch due to severe distortion of the aorta. As the stent continues to travel, the catheter is prone to fracture at the first curve of the descending aorta and increases the degree of distortion of the descending aorta. In addition, the patient is a 103-year-old man, and his blood vessels have aged to a terrible level, and none of us knows whether this kind of decayed blood vessels can support forcibly pushing the catheter and capsule in, in case it is forcibly pushed in, it may cause the wall of the descending aorta to be severely torn in the stent plane and bleed profusely...... "Director Yu said in a deep voice.

This is also his biggest concern!

This is the main reason why he did not dare to do this surgery!

"Combined with the current patient's situation, in fact, I still recommend using the anterograde approach through the apex!" Director Yu continued.

At present, in addition to being too old and seriously aging of blood vessels, the patient also has mild calcification of the iliac artery and femoral artery, and moderate calcification of the ascending aorta. At that time, if the catheter passes through these places if there is not enough space, it will not be able to pass, and if you choose to try to force it through, I am afraid that the aging blood vessels will not support this way!

If you choose to do CTO interventional surgery for the elderly to remove calcium, the risk is also very high!

Ruan Bin smiled after hearing this, he also knew that there are currently three surgical approaches for transcatheter aortic valve implantation, the first one: transfemoral vein anterograde route: puncture the femoral vein guidewire to the right atrium, puncture the atrial septum and dilate the puncture hole, use a floating catheter across the mitral valve and aortic valve opening, and send the catheter from the femoral artery to clamp the guidewire and pull it out of the body to establish a wire track.

Compared with the transarterial route, the heart pulse has less impact on the stent valve and is accurately positioned, and the larger inner diameter sheath can be used, and the stent valve is easy to pass through. However, this kind of path needs to puncture the atrial septum, which may cause cardiac tamponade, if the dilated puncture hole is large, the atrial septal defect can be left after surgery, and the large-diameter sheath crossing the mitral valve can cause valvular insufficiency or injury, and then cause hemodynamic abnormalities.

Second, the anterograde route through the apex: this operation requires general anesthesia and endotracheal intubation, the chest wall is incised anterolateral to the precordial area and the apex is exposed, and the left ventricular apex is punctured under rapid ventricular pacing, and a delivery track is established under X-ray fluoroscopy, and then the route is similar to the transfemoral route.

The advantage is to avoid damage to the peripheral artery, and it can be applied to patients who cannot operate through the femoral iliac artery, and the position of the valve can be observed and adjusted more intuitively, which reduces the damage to the aorta, thereby reducing the incidence of cerebral infarction. However, surgery requires surgical thoracotomy, which requires a high sterile environment for surgery, which will cause a certain degree of damage to patients.

This is the surgical approach recommended by Director Yu, mainly because Jiang Yurong's maternal great-grandfather has serious calcification of blood vessels in his heart, which is easy to cause arterial vascular damage. But using this transapical anterograde route can avoid damage to the aorta!

However, Ruan Bin felt that this approach required opening a 5 cm diameter wound on the chest wall and sending the artificial intervention valve to the body to replace the diseased valve.

After all, the old man is 103 years old, and if he can make an incision, he will not make an incision!

As for the third one, it is the one chosen by Ruan Bin - the retrograde route through the femoral artery: transfemoral artery → iliac artery → descending aorta→ aortic arch→ ascending aorta→ aortic valve→ left ventricle. The surgical procedure and approach are similar to those of percutaneous aortic stenosis balloon dilation, and the transvenous route is relatively simple.

This approach avoids mitral valve damage, but patients with arterial stenosis caused by peripheral arterial lesions have difficulty passing through the sheath and may damage peripheral arteries and may lead to cerebral infarction. It is necessary to cross the aortic arch and stenosis of the aortic valve, which is relatively difficult to operate.

The main reason is that the aortic arch of the old man is crooked, which is also one of the reasons why Director Yu strongly opposes Ruan Bin's approach!

Although transcatheter aortic valve replacement is indicated for patients who are at high surgical risk or who cannot be operated. Although it is a less invasive procedure, it has fatal complications, including the rare rupture of the descending aorta!

That's why he proposed to let the patient go to Jianxi Hospital for surgery!

Jianxi Hospital is currently the largest TAVI (transcatheter aortic valve implantation) teaching and training base in China!

"Director Yu, I know what you're worried about, what if I can solve these key difficulties?" Ruan Bin smiled slightly.

"Can you solve it?" Director Yu couldn't believe it.

"Of course, what I have to do is to perform CTO surgery on the old man first, first give him a calcified part such as the iliac artery→ descending aorta→ aortic arch → ascending aorta, and then perform transcatheter aortic valve implantation!"

"I know your CTO surgery is competent, but how do you deal with this aortic arch curvature? It's almost impossible to handle, right?" Director Yu frowned.

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