冠脈造影的規(guī)范操作技術(shù)和注意事項(xiàng)

1、冠脈造影的規(guī)范操作技術(shù)和注意事項(xiàng)冠脈造影仍是診斷CHD的“金標(biāo)準(zhǔn)”是PCI操作技術(shù)的基礎(chǔ)經(jīng)動脈系統(tǒng)操作：有血栓栓塞風(fēng)險導(dǎo)管進(jìn)入冠脈內(nèi)：有損傷冠脈口的風(fēng)險需引導(dǎo)導(dǎo)絲前引，有損傷血管的風(fēng)險需穿刺外周動脈、置入或拔出鞘管，有出血、血腫的風(fēng)險導(dǎo)管直接進(jìn)出血液循環(huán)系統(tǒng)，有感染風(fēng)險需使用對比劑，有過敏和對比劑腎病風(fēng)險因此，規(guī)范操作十分重要Left coronary distributionDominant LCXWrap-around LAD冠狀動脈血管樹解剖示意圖1.左主干12.圓錐支2.前降支近段13.右冠狀動脈近段3.前降支中段14.右冠狀動脈中段4.前降支遠(yuǎn)段15.右冠狀動脈遠(yuǎn)段5.第一對角支16

2、.房室結(jié)動脈6.第二對角支17.后降支7.回旋支近段18.左心室支8.回旋支遠(yuǎn)段19.右心室支9.鈍緣支20.銳緣支10.后降支21.室間隔穿支11.竇房結(jié)動脈22.左心房支Coronary Anomaly定義？ 是將冠造風(fēng)險降至最低甚至可避免的合理操作原則：需有效降低上述風(fēng)險甚至潛在風(fēng)險穿刺血管損傷沿途動脈損傷冠脈損傷心肌缺血過敏感染血栓栓塞規(guī)范操作：定義或原則？冠脈造影的基本步驟（1）操作準(zhǔn)備消毒、鋪巾、準(zhǔn)備心電壓力連接穿刺、鞘管準(zhǔn)備導(dǎo)管（肝素水）沖洗急救藥物準(zhǔn)備三聯(lián)三通準(zhǔn)備穿刺外周動脈，插入鞘管股動脈橈動脈肱動脈（應(yīng)嚴(yán)格指征）前送導(dǎo)管至升主動脈的根部需導(dǎo)絲引導(dǎo)避免操作阻力避免進(jìn)入沿途動脈

3、分支抽血排氣，監(jiān)測壓力冠脈造影的基本步驟（2）Seldinger technique Anterior Superior Iliac SpinePubisInguinal LiagmentThe maximal inguinal pulsation is over the CFA in 90% of casesFluoroscopically, the medial aspect of the femoral head marks the CFA. Puncture at this site will enter the CFA in 80% of casesThe midpoint betw

4、een the anterior superior iliac spine and the pubis located the CFA in most patientsHow to do a proper groin stick?Good punctureHigh PuncturePros and cons for radial approachAdvantages:The lowest access site complication rate.Early ambulation and early discharge.Lower procedural cost.Disadvantages:T

5、echnically more difficult.To use radial or not?Patient selectionObese ,elderly and patients with PVDPatients with bleeding risk ( lytic, on coumadin, GP2b/3a)Patient to avoidShockRaynauds, Buergers diseaseSmall artery even with normal Allen testRadial artery punctureComplex anatomyComplex anatomyCom

6、plex anatomyConsensus on radial accessTRA is an elegant, enthusiastic, profitable and reliable technique.TRA provides the lowest access site complication rate.TRA improves the comfort of the patient.TRA allows the use of most current devices and technique.TRA requires learningBrachial Artery Punctur

7、eBrachial Access IndicationFemoral or radial approach is not availableFemoral approach is dangerous ( aortic aneurysm )Unaccessible IMA by femoral approachExcessively obese patientRadial approach is preserved for cardiac surgeonBrachial Access DisadvantagesMore vascular complication (Thromboembolism

8、 Hematoma) than radial 2-3%Hard to compress( between the head and biceps)Nerve injury (median nerve is in the bundle)ACCESS: A Randomized Comparison of PTCA by the Radial, Brachial, and Femoral ApproachesKiemeneij, et al. JACC 1997;29: 1269-1275900 patients undergoing PTCA randomized to radial, brac

9、hial or femoral artery access site.Conclusions: Procedural and clinical outcomes were similar for the three subgroups.Access failure was more common during transradial PTCA.Major access site complications were more frequent after transbrachial and transfemoral PTCA.N=900Radial(n=300)Brachial(n=300)F

10、emoral(n=300)Successful Coronary Cannulation (%)93.095.799.7PTCA Success (%)91.790.790.7Event Free at 1 Month (%)88.087.790.0Major Entry Site Complications (%)02.32.0導(dǎo)管進(jìn)入左右冠脈口規(guī)律手法：“螺絲釘原則”特殊例外：升主動脈擴(kuò)張時避免注入氣體和血栓避免壓力嵌頓推注對比劑造影清晰顯像而對比劑最少持續(xù)推注對比劑3心動周期多體位投照，充分顯露病變部位和各段血管嚴(yán)密觀察ECG和血壓、心率變化冠脈造影的基本步驟（3）撤出造影導(dǎo)管血壓、心率

11、穩(wěn)定再撤緩慢均勻拔出鞘管，加壓包扎壓動脈而非靜脈壓住動脈穿刺點(diǎn)部位而非其它部位觀察術(shù)肢膚色、膚溫、動脈搏動和穿刺血管處有無血腫冠脈造影的基本步驟（4）冠脈造影的規(guī)范操作要點(diǎn)（1）操作準(zhǔn)備消毒、鋪巾，須符合無菌原則壓力連接排水：應(yīng)從“中央”向外排須用肝素水沖洗鞘、導(dǎo)管等三聯(lián)三通聯(lián)接至壓力、肝素鹽水和造影劑穿刺外周動脈準(zhǔn)確定位動脈穿刺點(diǎn)，不能太高和太低盡量一針見血避免穿透血管后壁鞘管導(dǎo)絲無阻力送入前送造影導(dǎo)管至主動脈根部透視幫助導(dǎo)絲前行，別誤入頸動脈和冠脈內(nèi)避免左冠一次進(jìn)入冠脈左主干口內(nèi)撤導(dǎo)絲、抽回血、接壓力、排氣體導(dǎo)管進(jìn)入冠脈口在冠脈口左前斜位進(jìn)（LAO 45o）規(guī)律手法：“擰螺絲釘原則”（順鐘

12、向進(jìn)，反之出，升主動脈擴(kuò)張者例外）操作輕柔，無阻力避免“頂進(jìn)”左冠口，和“跳進(jìn)”右冠內(nèi)注意特殊導(dǎo)管（如AL1）的特殊操作性：應(yīng)順暢冠脈造影的規(guī)范操作要點(diǎn)（2）推注造影劑造影應(yīng)快速而短暫（ 3心動周期）應(yīng)有造影劑從冠脈口反溢應(yīng)多個標(biāo)準(zhǔn)體位投照，顯全冠脈解剖嚴(yán)密觀察心率、血壓和心電圖的變化造影劑總量不能過多冠脈造影的規(guī)范操作要點(diǎn)（3）撤出導(dǎo)管“螺絲釘原則” （逆鐘向撤出）勻速緩慢撤出，防導(dǎo)管打結(jié)拔除鞘管，加壓包扎壓住動脈穿刺點(diǎn)包扎先緊后松股動脈血腫發(fā)生率很高橈動脈血腫也不少見嚴(yán)密觀察術(shù)肢膚色、膚溫、動脈搏動冠脈造影的規(guī)范操作要點(diǎn)（4）冠造中值得商榷的欠規(guī)范操作無菌操作不夠規(guī)范消毒皮膚：非“由內(nèi)向外

13、”壓力傳感器充水：非“由中央向外周”加壓袋充水系統(tǒng)，有氣栓風(fēng)險正位進(jìn)左冠口，非左冠切線位，有一定“盲目性”冠脈內(nèi)推注造影劑，時間過長有室顫和心臟停搏風(fēng)險冠脈導(dǎo)管的種類和品牌種類左冠導(dǎo)管右冠導(dǎo)管左、右共用導(dǎo)管（多用于橈動脈）Jndkins L. R特需造影導(dǎo)管：AL1-2，AR1-2 多用途 “橋”造影導(dǎo)管品牌：強(qiáng)生 Cordis、Medtronic等冠造導(dǎo)管的選擇依據(jù)冠造解剖開口位置：高、低，前、后開口走向：上斜、下斜升主動脈：寬、窄冠脈開口正常位置：Jndkins L、R冠脈開口異常開口過高、偏前、走向上斜：AL1-2升主動脈過寬，選Jndkins L、R5開口過低、或下斜走向：多用途？應(yīng)小

14、心造影導(dǎo)管的選擇主動脈根部的直徑（ 增寬、正常、縮?。┕诿}開口位置（高低、前后）冠脈開口的指向（向上、水平、向下）最重要的要求: 同軸性合適外型的導(dǎo)管 足夠的管徑建議使用6F導(dǎo)管同軸調(diào)整 未同軸 同軸彎曲/頭端長度3.04.05.0Judkins左PSP = 第一彎曲S = 第二彎曲頭端長度 = P-S距離(cm)彎曲/頭端距離Judkins 右SP頭端長度 = P-S 距離cm)P = 第一彎曲S = 第二彎曲3.04.05.0彎曲/頭端長度SPT1.02.03.0頭端長度 = P-S 距離(cm)P = 第一彎曲S = 第二彎曲T = 第三彎曲Amplatz左冠彎曲/頭端距離TSP1.02

15、.03.0頭端長度 = P-S 距離 (cm)P = 第一彎曲S = 第二彎曲T = 第三彎曲Amplatz右冠彎曲長度短彎: 適用于向上開口長彎: 適用于向下開口冠脈變異1. RCA - 正常2. RCA 高位，向前3. RCA 左竇, 向后4. LCA 正常5. LCA 高位，向前前后21345LAO 40RSVLSV指引導(dǎo)管的選擇：左冠解剖指引導(dǎo)管主動脈根部正常增寬縮小JL4, AL2, VL4, GL4, EB3.5, EBU4JL 5, AL 2, VL 4, GL 4, XB 4, EBU 4JL3.5, VL3.5, GL3.5, XB3.0, EBU3.5開口*正常，向前向后向

16、上JL, AL, VL, GL, XB, EBUAL, VL, GL, XB, EBUJL, VL, GL, XB, EBU超選擇LADLCXJL3.5, EBU (小半號）JL4.5, AL, JL, EBU)指引導(dǎo)管的選擇：右冠解剖指引導(dǎo)管主動脈根部正常增寬縮小JR4, AL1, AR1JR 5, AL 2, AR 2JR 3, AL 0.75開口*正常向前，向上向下牧羊鞭水平JR, AL, ARAL, HS, MP,IMAMP, AR, JRAL, SCR, VR, VRSC, DA, ELG, HS, Champ, IMAJR, HS, AR, VR*Size of curve dep

17、ends on aortic root diameterJudkins 導(dǎo)管超選擇造影向下開口的RCA(SR和大號JR導(dǎo)管)向上開口的RCA （HS和IMT導(dǎo)管）前向開口的RCA(AL和JR5導(dǎo)管)Amplatz造影導(dǎo)管Amplatz造影導(dǎo)管造影體位選擇：充分暴露病變常規(guī)體位：RCA：LAO45o：近、中、遠(yuǎn)段病變 Ap-Cranial：開口和遠(yuǎn)端病變 RAO30o：中段病變LCA：LAO45oCranial Caudal APCranial Caudal RAO30oCranial Caudal特殊體位：常規(guī)體位的“變異”左冠：右前斜加頭位后前位: 左冠右前斜位加頭位:左冠左前斜位加頭位:

18、左冠左前斜位加足位: 左冠右前斜位加足位: 左冠左冠：左側(cè)位右冠左前斜位似字母 “C”右冠右前斜位似字母 “L”Left coronary arteryLeft coronary arteryDominant left coronary arteryRight coronary artery（RCA）Right coronary artery （RCA）How to define left coronary artery pay attention to septal branches:RAO view of LCALAD runs horizontally on the upper bord

19、er of heart. LCX runs vertically to LAD. LAD may overlap with D. Finding out the septal branches may helpLAO view of LCALAD runs from the top middle to the bottom. LCX is on the right side and runs horizontally and finally take its course down . LADOMOM1 or Ramus ? LCXSeptalLCXOMLADDiagonalLMSeptalR

20、amusLCXOMLADLMLADDiagOMLCXLMLAD?RCAPLVPDARCAPDAAMPLVRCAPDAPLVAMSuggested angulation for coronary angiogram4. 25 LAO, 30 Ca5. 15 RAO, 20 Ca6. 20 LAO, 30 Cr1. 30 LAO2. 30 RAO3. 30 LAO, 30 Cr7. 15 RAO, 20 Ca8. 10 RAO, 40 Cr9. 10 RAO, 40 Cr冠脈造影中的常見問題原因及對策左冠：導(dǎo)管不能進(jìn)入原因：升主動脈過寬，導(dǎo)管夠不著 主動脈過迂曲，操作性差 在升主動脈夾層的假腔內(nèi)對策：換大號造影導(dǎo)管（