冠脉造影的规范操作.docx

2009年介入沙龙(CISC 2009)北京09-2-20 冠脉造影 ■仍是诊断CHD的“金标准” ■是PCI操作技术的基础 ■经动脉系统操作：有血栓栓塞风险 ■导管进入冠脉内：有损伤冠脉口的风险 ■需引导导丝前引，有损伤血管的风险 ■需穿刺外周动脉、置入或拔出鞘管，有出血、血肿 的风险 ■导管直接进出血液循环系统，有感染风险 ■需使用对比剂，有过敏和对比剂肾病风险 因此，规范操作十分重要 Anterior Cardiac Anterior R. Atrial Brandi of R. Coronary Arteiy Sm削 Cardiac Vein Sternocostal Aspect LCorona^ Artery Great Cardiac Vein Circumflex Branch of L Coronary Artery Anterior Intervenlricular (Anterior Descending) Branch d L Coronary Artery ri Superior Vena Caval Branch (Nodal Artery) Sinoatrial Artery Posterior Interventnciilar 3ranchof R. Coronary Artery I Diaphragmatic Aspect Left coronary distribution 冠状动脉血管树辩剖 示意 图 弟一纣為兑 扑?站二丹油須 \ 0.后阡立 rj 1 r) 20 主心空艾 书心：2? 堂间隔写卓 y Anomaly LhH Me” Goron日ry Artery Arising Fram the Right Sinus of Vaiaalva Gross-sectionai Representative RAO Representation Angtographic Features 规范操作：定义或原则? ■定义? 是将冠造风险降至最低甚至可避免的合理操作 ■原则：需有效降低上述风险甚至潜在风险 ?穿刺血管损伤 ?沿途动脉损伤 ?冠脉损伤 ?心肌缺血 ?过敏 ?感染 冠脉造影的基本步骤 冠脉造影的基本步骤(2) 冠脉造影的基本步骤 冠脉造影的基本步骤（1） ■操作准备 ?消毒、铺巾、准备心电压力连接 ?穿刺、鞘管准备 ?导管（肝素水）冲洗 ?急救药物准备 ?三联三通准备 ■穿刺外周动脉，插入鞘管 股动脉 極动脉 肱动脉(应严格指征) ■前送导管至升主动脉的根部 需导丝引导 避免操作阻力 避免进入沿途动脉分支 抽血排气，监测压力 Seidinger technique The maximal inguinal pulsation is over the CFA in 90% of cases Fluoroscopically, the medial aspect of the femoral head marks the CFA. Puncture at this site will enter the CFA in 80% of cases The midpoint between the anterior superior iliac spine and the pubis located the CFA in most patients How to do a proper groin stick? Pros and cons for radial approach Advantages: The lowest access site complication rate. ? Early ambulatiion and earlv diischarge. ? Lower procedural cost Disadvantages: Technically more difficult To use radial or not? Patient selection Obese .elderly and patients with PVD Patients with bleeding risk (lytic, on coumadin, GP2b/3a) Patient to avoid Shock Raynauds, Buergers disease Small artery even with normal Allen test ry puncture plinciurCs I poiE I Complex anatomy Complex anatomy Complex anatomy Consensus on radial access TRA is an elegan