頸動(dòng)脈支架手術(shù)步課件

循序漸進(jìn)建立標(biāo)準(zhǔn)

股動(dòng)脈穿刺7For8F的套管針7F用于8mm以下的CarotidWallstent?Monorail?

8F用于10mm以下的CarotidWallstent?Monorail?1.建立動(dòng)脈通道2.血管造影確定病變選擇性頸總動(dòng)脈造影.035”標(biāo)準(zhǔn)導(dǎo)絲4For5F造影導(dǎo)管ImagerIIHeadhunterorSidewinder3.指引導(dǎo)管定位

置stiff.035”導(dǎo)絲于頸外動(dòng)脈通過(guò)Y接頭，置指引導(dǎo)管于頸動(dòng)脈分叉處下1-2cm移出.035”導(dǎo)絲4.

FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)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(hù)盤(pán)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(lái)4-1FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

準(zhǔn)備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(dòng)輸送鞘向上覆蓋濾網(wǎng)，排除空氣導(dǎo)絲頭端通過(guò)剝離鞘，置濾網(wǎng)導(dǎo)絲于Y閥中4-1FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

準(zhǔn)備4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇

濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cm4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇3cmminimum1.5cmminimum血管直徑介于3.5–5.5mm之間5.5mm3.5mm4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇

濾網(wǎng)放置于至少有2cm長(zhǎng)的直血管鎳鈦環(huán)距血管轉(zhuǎn)彎處距離應(yīng)>1cm4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇ImagerIIHeadhunterorSidewinderAstheWallstentdeploys,itshortensfrombothendstowardsthemiddle（可見(jiàn)到鎳鈦環(huán)已進(jìn)入到鞘遠(yuǎn)端的標(biāo)記中）視角2:confirmappositionwithcrescentshapeFLOW: 定期檢查血流Advancethestentsothattheradiopaquemarkersarepositionedeithersideofthelesiontobestented濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cm4-1FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

準(zhǔn)備IfitisnecessarytoplaceasecondCarotidWallstentFilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置Contrastmediumcanbeinjectedthroughtheguidingcatheterallowaminimumoverlapof5mm視角1:Appearsapposed鎳鈦環(huán)距血管轉(zhuǎn)彎處距離應(yīng)>1cm濾網(wǎng)放置于至少有2cm長(zhǎng)的直血管確定支架兩端的標(biāo)記在病變外端CarotidWallstent?DeploymentTechniqueReview4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇注意不要移動(dòng)濾網(wǎng)肝素鹽水5ml沖洗支架內(nèi)腔，見(jiàn)鹽水從導(dǎo)絲口流出4-3FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

進(jìn)入&前進(jìn)onehandandtwohandstech

buddywire?/4-3FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

進(jìn)入&前進(jìn)4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放視角1:Appearsapposed視角2:confirmappositionwithcrescentshape

視角2:Notapposed4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)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(gè)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(guò)剝離的方式，抽出輸送鞘，釋放濾網(wǎng)A: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PredeploymentPostdeploymentABCDEABCDE4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流

隨時(shí)穩(wěn)定導(dǎo)絲交換器械時(shí)交換指引導(dǎo)管時(shí)4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流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，CheckFlow4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流1.PLACEMENT: 確定濾網(wǎng)完全貼壁2.POSITION:手術(shù)的全過(guò)程中,保持濾網(wǎng)的位置不變3.FLOW: 定期檢查血流4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放在病變遠(yuǎn)端植入好FWEZ?遠(yuǎn)端保護(hù)裝置后，沿FWEZ?的導(dǎo)絲將球囊推送到病變處注意不要移動(dòng)濾網(wǎng)5.球囊預(yù)擴(kuò)張球囊預(yù)擴(kuò)張是為增加支架的通過(guò)性作準(zhǔn)備AstheWallstentdeploys,itshortensfrombothendstowardsthemiddleIfitisnecessarytoplaceasecondCarotidWallstentCAUTION:IfthetipoftheCarotidWallstentnoseconecatchesthedistalends,freeitwithgentlemovements!POSITION:手術(shù)的全過(guò)程中,保持濾網(wǎng)的位置不變堵住導(dǎo)絲口，繼續(xù)沖洗，可見(jiàn)鹽水從導(dǎo)管頭端（鞘管頭端標(biāo)記處）流出，4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放如果血流停止，立即撤出，4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)FLOW: 定期檢查血流IfitisnecessarytoplaceasecondCarotidWallstent4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放DeploytheCarotidWallstentslowlyafewmillimetersatatimePostdeployment濾網(wǎng)放置于至少有2cm長(zhǎng)的直血管4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放TheGuideCathetercannowbewithdrawnandtheprocedurecompletedinthenormalwayCarotidWallstent?Deployment6.頸動(dòng)脈支架術(shù)CarotidWallstent?Monorail?Placement支架的準(zhǔn)備：閱讀指南確保無(wú)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(jiàn)鹽水從導(dǎo)絲口流出堵住導(dǎo)絲口，繼續(xù)沖洗，可見(jiàn)鹽水從導(dǎo)管頭端（鞘管頭端標(biāo)記處）流出，InsertionLoadthestentcatheterontotheproximalendoftheFilterWireEX?guidewireandadvancetheCarotidWallstent?tothelesion沿著保護(hù)傘導(dǎo)絲送支架到病變處Maintainthedeliveryinstrumentasstraightaspossibleoutsidethebody保持體外輸送系統(tǒng)盡量直Advancethestentsothattheradiopaquemarkersarepositionedeithersideofthelesiontobestented確定支架兩端的標(biāo)記在病變外端IfitisnecessarytoplaceasecondCarotidWallstent allowaminimumoverlapof5mm如果有用第二個(gè)支架，重疊部分最少要有5mm6.頸動(dòng)脈支架術(shù)CarotidWallstent?DeploymentTechniqueReviewAstheWallstentdeploys,itshortensfrombothendstowardsthemiddle支架釋放后，長(zhǎng)度從兩端向中間縮短PlacetheproximalanddistalX-raymarkersintheinnershaftoverlappingbothsidesofthestenosis內(nèi)桿上支架兩端的標(biāo)記要超過(guò)狹窄的范圍DeploytheCarotidWallstentslowlyafewmillimetersatatime釋放支架需要較慢的速度Uptoabouthalfwayitispossibletorecapturethestentandre-positionit支架釋放一半以上時(shí)，還可以重新回收，重新定位6.頸動(dòng)脈支架術(shù)CarotidWallstent?DeploymentImmobilizethestainlesssteeltube固定不銹鋼管SlidetheT-connectorgentlytowardstheblackreleasemarkeruntiltheCarotidWallstentis 50%deployed.在支架釋放小于50%時(shí)，將T連接向黑色釋放標(biāo)記移動(dòng)，CheckpositionofthepartiallydeployedCarotidWallstentwithinthestenosis檢查狹窄病變內(nèi)部分釋放的支架Contrastmediumcanbeinjectedthroughtheguidingcatheter造影劑可以通過(guò)指引導(dǎo)管注入CAUTION:Donotpushthestainlesssteeltube!注意：千萬(wàn)不要推動(dòng)不銹鋼管6.頸動(dòng)脈支架術(shù)CarotidWallstent?DeploymentImmobilizethestainlesssteeltubeagainWhentheCarotidWallstentisinitsfinalposition,gentlyslidetheT-connectoronthestainlesssteeltubetowardstheheartshapedhubuntilthestentiscompletelydeployed.Carefullyremovethestentcatheter,underfluoroscopicguidance,leavingtheguidewireinplace支架定位后，固定不銹鋼管，向前推動(dòng)T管，完全釋放支架CAUTION:IfthetipoftheCarotidWallstentnoseconecatchesthedistalends,freeitwithgentlemovements!如果支架的頭端觸及濾網(wǎng)的遠(yuǎn)端，輕柔將其移開(kāi)6.頸動(dòng)脈支架術(shù)6.頸動(dòng)脈支架術(shù)7.球囊后擴(kuò)張后擴(kuò)的目的：Ensuregoodin-flowandout-flowcharacteristic確保流速正常Goodstenttowallapposition支架貼壁更好CAUTION:CloselymonitortheECGtraceintheeventofbradycardiaduringthepostdilatationstep.注意：如果后擴(kuò)時(shí)出現(xiàn)心動(dòng)過(guò)緩，密切注意心電圖軌跡.ControlAngiogram？？Performacontrolangiogramtoconfirmresultofstentplacement4-6FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

回撤4-6FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)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(jiàn)到鎳鈦環(huán)已進(jìn)入到鞘遠(yuǎn)端的標(biāo)記中）將整個(gè)的回撤鞘連同濾網(wǎng)導(dǎo)絲作為一個(gè)整體同時(shí)撤出4-6FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

回撤4.

FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

FilterwireEZ“EASY”FinalResultsTheGuideCathetercannowbewithdrawnandtheprocedurecompletedinthenormalwayThankYouforyourAttention!注意：千萬(wàn)不要推動(dòng)不銹鋼管（可見(jiàn)到鎳鈦環(huán)已進(jìn)入到鞘遠(yuǎn)端的標(biāo)記中）5cmminimum視角1:Appearsapposed4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cm支架釋放后，長(zhǎng)度從兩端向中間縮短3cmminimum7For8F的套管針PlacetheproximalanddistalX-raymarkersintheinnershaftoverlappingbothsidesofthestenosisallowaminimumoverlapof5mmAstheWallstentdeploys,itshortensfrombothendstowardsthemiddleCarotidWallstent?Monorail?Placement確定支架兩端的標(biāo)記在病變外端4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流ImagerIIHeadhunterorSidewinder旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放AstheWallstentdeploys,itshortensfrombothendstowardsthemiddleFLOW: 定期檢查血流

濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cm4-2FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

理想的位置選擇3cmminimum1.5cmminimum視角1:Appearsapposed視角2:confirmappositionwithcrescentshape

視角2:Notapposed4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)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(gè)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(guò)剝離的方式，抽出輸送鞘，釋放濾網(wǎng)4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放CarotidWallstent?DeploymentTechniqueReviewAstheWallstentdeploys,itshortensfrombothendstowardsthemiddle支架釋放后，長(zhǎng)度從兩端向中間縮短PlacetheproximalanddistalX-raymarkersintheinnershaftoverlappingbothsidesofthestenosis內(nèi)桿上支架兩端的標(biāo)記要超過(guò)狹窄的范圍DeploytheCarotidWallstentslowlyafewmillimetersatatime釋放支架需要較慢的速度Uptoabouthalfwayitispossibletorecapturethestentandre-positionit支架釋放一半以上時(shí)，還可以重新回收，重新定位6.頸動(dòng)脈支架術(shù)4-6FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

回撤allowaminimumoverlapof5mmCarotidWallstent?Monorail?PlacementAstheWallstentdeploys,itshortensfrombothendstowardsthemiddle撤除輸送鞘，遠(yuǎn)端濾網(wǎng)顯露出來(lái)MaintainthedeliveryinstrumentasstraightaspossibleoutsidethebodyPlacetheproximalanddistalX-raymarkersintheinnershaftoverlappingbothsidesofthestenosis確定支架兩端的標(biāo)記在病變外端ImagerIIHeadhunterorSidewinderFLOW: 定期檢查血流Ensuregoodin-flowandout-flowcharacteristic視角2:confirmappositionwithcrescentshape4-6FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

回撤確定支架兩端的標(biāo)記在病變外端WhentheCarotidWallstentisinitsfinalposition,gentlyslidetheT-connectoronthestainlesssteeltubetowardstheheartshapedhubuntilthestentiscompletelydeployed.FilterwireEZFLOW: 定期檢查血流allowaminimumoverlapof5mm035”導(dǎo)絲于頸外動(dòng)脈FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置5cmminimum4-1FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

準(zhǔn)備buddywire?/視角2:confirmappositionwithcrescentshape濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cmPOSITION:手術(shù)的全過(guò)程中,保持濾網(wǎng)的位置不變onehandandtwohandstech旋緊扭控器，固定導(dǎo)絲/濾網(wǎng)4-4FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

定位&釋放沿著濾網(wǎng)導(dǎo)絲，用回撤鞘將濾網(wǎng)完全地回收至鞘內(nèi)FLOW: 定期檢查血流4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流確定支架兩端的標(biāo)記在病變外端AstheWallstentdeploys,itshortensfrombothendstowardsthemiddle支架釋放后，長(zhǎng)度從兩端向中間縮短ControlAngiogram？？支架的準(zhǔn)備：4-3FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

進(jìn)入&前進(jìn)ImagerIIHeadhunterorSidewinderCarotidWallstent?DeploymentTechniqueReviewAstheWallstentdeploys,itshortensfrombothendstowardsthemiddleWhentheCarotidWallstentisinitsfinalposition,gentlyslidetheT-connectoronthestainlesssteeltubetowardstheheartshapedhubuntilthestentiscompletelydeployed.3cmminimumPOSITION:手術(shù)的全過(guò)程中,保持濾網(wǎng)的位置不變AstheWallstentdeploys,itshortensfrombothendstowardsthemiddle肝素鹽水5ml沖洗支架內(nèi)腔，見(jiàn)鹽水從導(dǎo)絲口流出濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cmCarotidWallstent?Monorail?Placement如果血流停止，立即撤出，4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流視角2:confirmappositionwithcrescentshape濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3cm4–5FilterWireEZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

穩(wěn)定&血流AstheWallstentdeploys,itshortensfrombothendstowardsthemiddleAstheWallstentdeploys,itshortensfrombothendstowardsthemiddle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)Loa