頸動脈支架手術(shù)步版課件

1、循序漸進 建立標(biāo)準(zhǔn) 循序漸進 建立標(biāo)準(zhǔn) 股動脈穿刺7F or 8F 的套管針7F 用于 8mm 以下的 Carotid Wallstent Monorail 8F 用于10 mm 以下的 Carotid Wallstent Monorail1.建立動脈通道股動脈穿刺1.建立動脈通道2. 血管造影確定病變選擇性頸總動脈造影.035” 標(biāo)準(zhǔn)導(dǎo)絲4F or 5F 造影導(dǎo)管Imager II Headhunter or Sidewinder2. 血管造影確定病變選擇性頸總動脈造影3. 指引導(dǎo)管定位 置 stiff .035” 導(dǎo)絲于頸外動脈 通過Y接頭，置指引導(dǎo)管于頸動脈分叉處下1-2 cm 移出 .

2、035” 導(dǎo)絲3. 指引導(dǎo)管定位 置 stiff .035” 導(dǎo)絲于頸外4. FilterWire EZ動脈遠(yuǎn)端保護裝置回撤鞘和輸送鞘（附有濾網(wǎng)的導(dǎo)絲）分別置于不同的保護盤內(nèi)黑色尾端：附有濾網(wǎng)的導(dǎo)絲和輸送鞘白色尾端: 回撤鞘撤除輸送鞘，遠(yuǎn)端濾網(wǎng)顯露出來4. FilterWire EZ動脈遠(yuǎn)端保護裝置回撤鞘和輸4-1 FilterWire EZ動脈遠(yuǎn)端保護裝置 準(zhǔn) 備4-1 FilterWire EZ動脈遠(yuǎn)端保護裝置 用肝素鹽水在原位沖洗輸送鞘 取出附有濾網(wǎng)的導(dǎo)絲及輸送鞘 濾網(wǎng)頭端浸泡于肝素鹽水中，移動輸送鞘向上覆蓋濾網(wǎng)，排除空氣 導(dǎo)絲頭端通過剝離鞘，置濾網(wǎng)導(dǎo)絲于Y閥中4 - 1 FilterW

3、ire EZ動脈遠(yuǎn)端保護裝置 準(zhǔn) 備 用肝素鹽水在原位沖洗輸送鞘4 - 1 FilterWi4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cmFinal Results肝素鹽水5ml沖洗支架內(nèi)腔，見鹽水從導(dǎo)絲口流出As the Wallstent deploys, it shortens from both ends towards the middleContrast medium can be injected through the guiding catheter內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍肝素鹽水5ml沖洗支架內(nèi)腔，見鹽

4、水從導(dǎo)絲口流出4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇將整個的回撤鞘連同濾網(wǎng)導(dǎo)絲作為一個整體同時撤出Attention !4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置 穩(wěn) 定 & 血 流5 cm minimumPerform a control angiogram to confirm result of stent placementFilterWire EZ動脈遠(yuǎn)端保護裝置If it is necessary to place a second Carotid Wallstent支架釋放一半以上時，還可以重新回收，重新定位肝素鹽水5ml沖洗支架內(nèi)腔，見鹽

5、水從導(dǎo)絲口流出4F or 5F 造影導(dǎo)管4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cm4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇3 cm minimum1.5 cm minimum 濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cm4 - 2 Fil 血管直徑介于3.5 5.5mm之間5.5mm3.5mm4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇5.5mm3.5mm4 - 2 FilterWire EZ如果血流停止，立即撤出，如果血流停止

6、，立即撤出，4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤one hand and two hands tech如果血流停止，立即撤出，用肝素鹽水在原位沖洗輸送鞘one hand and two hands tech在支架釋放小于50%時，將T連接向黑色釋放標(biāo)記移動，內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍如果有用第二個支架，重疊部分最少要有5mm4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇When the Carotid Wallstent is in its final position, gently slide the T-connector on

7、 the stainless steel tube towards the heart shaped hub until the stent is completely deployed.Place the proximal and distal X-ray markers in the inner shaft overlapping both sides of the stenosis通過剝離的方式，抽出輸送鞘，釋放濾網(wǎng)4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤one hand and two hands tech如果血流較緩，須重新定位和釋放內(nèi)桿上支架兩端的標(biāo)記要超過狹

8、窄的范圍內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍Carotid WallstentDeployment取出附有濾網(wǎng)的導(dǎo)絲及輸送鞘支架釋放后，長度從兩端向中間縮短 濾網(wǎng)放置于至少有2cm長的直血管 鎳鈦環(huán)距血管轉(zhuǎn)彎處距離應(yīng) 1cm4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇如果血流停止，立即撤出， 濾網(wǎng)放置于至少有2cm長的直血管4 - 3 FilterWire EZ動脈遠(yuǎn)端保護裝置 進 入 & 前 進4 - 3 FilterWire EZ動脈遠(yuǎn)端保護裝置 one hand and two hands tech buddy wire ?/4 - 3 FilterWire E

9、Z動脈遠(yuǎn)端保護裝置 進 入 & 前 進 one hand and two hands tech4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置視角 1: Appears apposed視角 2: confirm apposition with crescent shape 視角 2: Not apposed4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放 旋緊扭控器，固定導(dǎo)絲/濾網(wǎng) 濾網(wǎng)定位，從兩個不同的角度（垂直）造影以確定鎳鈦環(huán)是否緊貼血管壁 通過剝離的方式，抽出輸送鞘，釋放濾網(wǎng)視角

10、1: Appears apposed視角 2: cA: 導(dǎo)絲的頭端B: 濾網(wǎng)遠(yuǎn)端標(biāo)記C: 輸送鞘標(biāo)記D: 鎳鈦環(huán)E: 濾網(wǎng)近端標(biāo)記Pre deploymentPost deploymentABCDEABCDE4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放A: 導(dǎo)絲的頭端Pre deploymentPost dep4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置 穩(wěn) 定 & 血 流4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置 隨時穩(wěn)定導(dǎo)絲 交換器械時 交換指引導(dǎo)管時4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置 穩(wěn) 定 & 血 流 隨時穩(wěn)定導(dǎo)絲4 5 Fi

11、lterWire EZ定期檢查血流 如果血流較緩，須重新定位和釋放 如果血流停止，立即撤出，Check Flow4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置 穩(wěn) 定 & 血 流定期檢查血流Check Flow4 5 FilterW1. PLACEMENT: 確定濾網(wǎng)完全貼壁2. POSITION:手術(shù)的全過程中,保持濾網(wǎng)的位置不變3. FLOW:定期檢查血流4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置 穩(wěn) 定 & 血 流4 5 FilterWire EZ動脈遠(yuǎn)端保護裝置4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放4 FilterWire EZ動脈遠(yuǎn)端保護裝置確

12、定支架兩端的標(biāo)記在病變外端內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍Contrast medium can be injected through the guiding catheter035” 導(dǎo)絲于頸外動脈CAUTION: If the tip of the Carotid Wallstent nose cone catches the distal ends, free it with gentle movements!4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤通過Y接頭，置指引導(dǎo)管于頸動脈分叉處下1-2 cmone hand and two hands tech支架釋放

13、一半以上時，還可以重新回收，重新定位Pre deploymentone hand and two hands tech4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤支架釋放后，長度從兩端向中間縮短支架定位后，固定不銹鋼管，向前推動T管，完全釋放支架旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)Carotid WallstentDeployment內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍Ensure good in-flow and out-flow characteristic4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放釋放支架需要較慢的速度視角 1: Appears a

14、pposed4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放 在病變遠(yuǎn)端植入好FW EZ遠(yuǎn)端保護裝置后， 沿FW EZ的導(dǎo)絲將球囊推送到病變處 注意不要移動濾網(wǎng)5. 球囊預(yù)擴張球囊預(yù)擴張是為增加支架的通過性作準(zhǔn)備確定支架兩端的標(biāo)記在病變外端5. 球囊預(yù)擴張球囊預(yù)擴張是為增6. 頸動脈支架術(shù)Carotid Wallstent Monorail Placement 支架的準(zhǔn)備：閱讀指南確保無菌確定支架密封在鞘管內(nèi) 沖洗裝置： 肝素鹽水5ml沖洗支架內(nèi)腔，見鹽水從導(dǎo)絲口流出 堵住導(dǎo)絲口，繼續(xù)沖洗，可見鹽水從導(dǎo)管頭端（鞘管頭端標(biāo)記處）流出，6. 頸動脈支架術(shù)Carotid W

15、allstent MoInsertionLoad the stent catheter onto the proximal end of the FilterWire EX guidewire and advance the Carotid Wallstent to the lesion沿著保護傘導(dǎo)絲送支架到病變處Maintain the delivery instrument as straight as possible outside the body保持體外輸送系統(tǒng)盡量直Advance the stent so that the radiopaque markers are posit

16、ioned either side of the lesion to be stented確定支架兩端的標(biāo)記在病變外端If it is necessary to place a second Carotid Wallstent allow a minimum overlap of 5mm如果有用第二個支架，重疊部分最少要有5mm6. 頸動脈支架術(shù)Insertion6. 頸動脈支架術(shù)Carotid Wallstent Deployment Technique ReviewAs the Wallstent deploys, it shortens from both ends towards th

17、e middle 支架釋放后，長度從兩端向中間縮短 Place the proximal and distal X-ray markers in the inner shaft overlapping both sides of the stenosis內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍Deploy the Carotid Wallstent slowly a few millimeters at a time釋放支架需要較慢的速度Up to about half way it is possible to recapture the stent and re-position it支架釋放

18、一半以上時，還可以重新回收，重新定位6. 頸動脈支架術(shù)Carotid Wallstent Deployment Carotid WallstentDeploymentImmobilize the stainless steel tube 固定不銹鋼管Slide the T-connector gently towards the black release marker until the Carotid Wallstent is 50% deployed. 在支架釋放小于50%時，將T連接向黑色釋放標(biāo)記移動，Check position of the partially deployed C

19、arotid Wallstent within the stenosis 檢查狹窄病變內(nèi)部分釋放的支架Contrast medium can be injected through the guiding catheter造影劑可以通過指引導(dǎo)管注入CAUTION: Do not push the stainless steel tube!注意：千萬不要推動不銹鋼管6. 頸動脈支架術(shù)Carotid WallstentDeployment6.Carotid WallstentDeploymentImmobilize the stainless steel tube againWhen the Ca

20、rotid Wallstent is in its final position, gently slide the T-connector on the stainless steel tube towards the heart shaped hub until the stent is completely deployed.Carefully remove the stent catheter, under fluoroscopic guidance, leaving the guidewire in place支架定位后，固定不銹鋼管，向前推動T管，完全釋放支架CAUTION: If

21、 the tip of the Carotid Wallstent nose cone catches the distal ends, free it with gentle movements!如果支架的頭端觸及濾網(wǎng)的遠(yuǎn)端，輕柔將其移開6. 頸動脈支架術(shù)Carotid WallstentDeployment6.6. 頸動脈支架術(shù)6. 頸動脈支架術(shù)7. 球囊后擴張后擴的目的：Ensure good in-flow and out-flow characteristic確保流速正常Good stent to wall apposition支架貼壁更好CAUTION: Closely monit

22、or the ECG trace in the event of bradycardia during the post dilatation step.注意：如果后擴時出現(xiàn)心動過緩，密切注意心電圖軌跡7. 球囊后擴張后擴的目的：. Control Angiogram？Perform a control angiogram to confirm result of stent placement. Control Angiogram？4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤 4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置4 - 6 FilterWire EZ動脈遠(yuǎn)

23、端保護裝置 回 撤 沿著濾網(wǎng)導(dǎo)絲，用回撤鞘將濾網(wǎng)完全地回收至鞘內(nèi) （可見到鎳鈦環(huán)已進入到鞘遠(yuǎn)端的標(biāo)記中） 將整個的回撤鞘連同濾網(wǎng)導(dǎo)絲作為一個整體同時撤出4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤 4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置When the Carotid Wallstent is in its final position, gently slide the T-connector on the stainless steel tube towards the heart shaped hub

24、 until the stent is completely deployed.Advance the stent so that the radiopaque markers are positioned either side of the lesion to be stented如果血流停止，立即撤出，4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放視角 2: confirm apposition with crescent shapeEnsure good in-flow and out-flow characteristicPerform a control

25、 angiogram to confirm result of stent placementWhen the Carotid Wallstent is in its final position, gently slide the T-connector on the stainless steel tube towards the heart shaped hub until the stent is completely deployed.buddy wire ?/濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cm取出附有濾網(wǎng)的導(dǎo)絲及輸送鞘旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍

26、如果有用第二個支架，重疊部分最少要有5mmCarotid Wallstent Deployment Technique ReviewPre deploymentAttention !Perform a control angiogram to confirm result of stent placementDeploy the Carotid Wallstent slowly a few millimeters at a time在支架釋放小于50%時，將T連接向黑色釋放標(biāo)記移動，4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放4 - 6 FilterWire EZ

27、動脈遠(yuǎn)端保護裝置 回 撤4 . FilterWire EZ動脈遠(yuǎn)端保護裝置Filterwire EZ“EASY”When the Carotid Wallstent is Final ResultsThe Guide Catheter can now be withdrawn and the procedure completed in the normal wayFinal ResultsThank You for your Attention !Thank You 濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cm4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理想的位置選擇3 cm minim

28、um1.5 cm minimum 濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cm4 - 2 Fil視角 1: Appears apposed視角 2: confirm apposition with crescent shape 視角 2: Not apposed4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放 旋緊扭控器，固定導(dǎo)絲/濾網(wǎng) 濾網(wǎng)定位，從兩個不同的角度（垂直）造影以確定鎳鈦環(huán)是否緊貼血管壁 通過剝離的方式，抽出輸送鞘，釋放濾網(wǎng)視角 1: Appears apposed視角 2: c4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放4 FilterW

29、ire EZ動脈遠(yuǎn)端保護裝置Carotid Wallstent Deployment Technique ReviewAs the Wallstent deploys, it shortens from both ends towards the middle 支架釋放后，長度從兩端向中間縮短 Place the proximal and distal X-ray markers in the inner shaft overlapping both sides of the stenosis內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍Deploy the Carotid Wallstent slow

30、ly a few millimeters at a time釋放支架需要較慢的速度Up to about half way it is possible to recapture the stent and re-position it支架釋放一半以上時，還可以重新回收，重新定位6. 頸動脈支架術(shù)Carotid Wallstent Deployment 旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)濾網(wǎng)定位，從兩個不同的角度（垂直）造影以確定鎳鈦環(huán)是否緊貼血管壁如果血流停止，立即撤出，F(xiàn)inal Results肝素鹽水5ml沖洗支架內(nèi)腔，見鹽水從導(dǎo)絲口流出濾網(wǎng)環(huán)最頂點距離病變遠(yuǎn)端至少3 cmCarotid Wal

31、lstentDeployment通過剝離的方式，抽出輸送鞘，釋放濾網(wǎng)造影劑可以通過指引導(dǎo)管注入旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)Contrast medium can be injected through the guiding catheter撤除輸送鞘，遠(yuǎn)端濾網(wǎng)顯露出來在支架釋放小于50%時，將T連接向黑色釋放標(biāo)記移動，Good stent to wall apposition4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤5 cm minimum內(nèi)桿上支架兩端的標(biāo)記要超過狹窄的范圍Pre deploymentIf it is necessary to place a second

32、 Carotid Wallstent支架釋放一半以上時，還可以重新回收，重新定位支架釋放一半以上時，還可以重新回收，重新定位Attention !4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤 旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)4 - 6 FilterWirePlace the proximal and distal X-ray markers in the inner shaft overlapping both sides of the stenosisCarotid Wallstent Deployment Technique Review5 cm minimumEnsure g

33、ood in-flow and out-flow characteristicPOSITION:手術(shù)的全過程中,保持濾網(wǎng)的位置不變4 - 3 FilterWire EZ動脈遠(yuǎn)端保護裝置 進 入 & 前 進When the Carotid Wallstent is in its final position, gently slide the T-connector on the stainless steel tube towards the heart shaped hub until the stent is completely deployed.FilterWire EZ動脈遠(yuǎn)端保護裝

34、置釋放支架需要較慢的速度4 - 3 FilterWire EZ動脈遠(yuǎn)端保護裝置 進 入 & 前 進沿FW EZ的導(dǎo)絲將球囊推送到病變處4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放沿FW EZ的導(dǎo)絲將球囊推送到病變處支架釋放后，長度從兩端向中間縮短Carotid Wallstent Deployment Technique Review4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放FilterWire EZ動脈遠(yuǎn)端保護裝置用肝素鹽水在原位沖洗輸送鞘Attention !035” 導(dǎo)絲于頸外動脈5 cm minimum5 cm minimu

35、m通過Y接頭，置指引導(dǎo)管于頸動脈分叉處下1-2 cm將整個的回撤鞘連同濾網(wǎng)導(dǎo)絲作為一個整體同時撤出如果血流較緩，須重新定位和釋放When the Carotid Wallstent is in its final position, gently slide the T-connector on the stainless steel tube towards the heart shaped hub until the stent is completely deployed.4 - 3 FilterWire EZ動脈遠(yuǎn)端保護裝置 進 入 & 前 進Perform a control ang

36、iogram to confirm result of stent placement4 - 6 FilterWire EZ動脈遠(yuǎn)端保護裝置 回 撤Contrast medium can be injected through the guiding catheter4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放循序漸進 建立標(biāo)準(zhǔn)Final ResultsImmobilize the stainless steel tube again注意：千萬不要推動不銹鋼管5 cm minimum035” 導(dǎo)絲于頸外動脈4 - 2 FilterWire EZ動脈遠(yuǎn)端保護裝置 理

37、想的位置選擇Pre deployment如果血流停止，立即撤出，4 - 4 FilterWire EZ動脈遠(yuǎn)端保護裝置 定 位 & 釋 放旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)As the Wallstent deploys, it shortens from both ends towards the middleEnsure good in-flow and out-flow characteristicFLOW:定期檢查血流Perform a control angiogram to confirm result of stent placement支架的準(zhǔn)備：Place the proximal and distal X-ray markers in the inner shaft overlapping both sides of the stenosisCAUTION: If the tip of the Carotid Wallstent nose cone catches the distal ends, free it with gentle movements!沿FW EZ的導(dǎo)絲將球囊推送到病變處4 - 4 Filte