冠脉造影的规范操作

Successful Coronary Cannulation (%) 93.0 95.7 99.7
• TRA improves the comfort of the patient. • TRA allows the use of most current devices and
technique. • TRA requires learning
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Brachial Artery Puncture
5.第一对角支 16.房室结动脉
6.第二对角支 17.后降支
7.回旋支近段 18.左心室支
8.回旋支远段 19.右心室支
9.钝缘支
20.锐缘支
10.后降支
21.室间隔穿支
11.窦房结动脉 22.左心房支
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Coronary Anomaly
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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
• Disadvantages: • Technically more difficult.
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To use radial or not?
Patient selection • Obese ,elderly and patients with PVD • Patients with bleeding risk ( lytic, on
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Complex anatomy
awk.baidu.com
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Complex anatomy
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Consensus on radial access
• TRA is an elegant, enthusiastic, profitable and reliable technique.
• TRA provides the lowest access site complication rate.
coumadin, GP2b/3a)
Patient to avoid • Shock • Raynaud’s, Buerger’s disease • Small artery even with normal Allen test
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Radial artery puncture
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Complex anatomy
Approaches
900 patients undergoing PTCA randomized to radial, brachial or femoral artery access site.
N=900
Radial (n=300 Brachial Femoral
) (n=300) (n=300)
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 血栓栓塞
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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
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冠脉造影的基本步骤（2）
穿刺外周动脉，插入鞘管
Pubis
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How to do a proper groin stick?
Good puncture
High
Puncture
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Pros and cons for radial approach
• Advantages: • The lowest access site complication rate. • Early ambulation and early discharge. • Lower procedural cost.
• The midpoint between the anterior superior iliac spine and the pubis located the CFA in most patients
Anterior Superior Iliac Spine Inguinal Liagment
• Hard to compress( between the head and biceps) • Nerve injury (median nerve is in the bundle)
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ACCESS: A Randomized Comparison of PTCA by the Radial, Brachial, and Femoral
冠脉造影的规范操作
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Left coronary distribution
Dominant LCX
a Wrap-around LAD
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冠状动脉血管树解剖示意图
1.左主干
12.圆锥支
2.前降支近段 13.右冠状动脉近段
3.前降支中段 14.右冠状动脉中段
4.前降支远段 15.右冠状动脉远段
• Excessively obese patient
• Radial approach is preserved for cardiac surgeon
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Brachial Access Disadvantages
• More vascular complication (Thromboembolism Hematoma) than radial 2-3%
股动脉
桡动脉
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
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Seldinger technique
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• 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
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Brachial Access Indication
• Femoral or radial approach is not available
• Femoral approach is dangerous ( aortic aneurysm )
• Unaccessible IMA by femoral approach