脑血管介入流程PPT课件.ppt

1、12目的目的3目的目的4567头颈部听诊头颈部听诊颈动脉分叉部（颈动脉）：甲状软颈动脉分叉部（颈动脉）：甲状软骨骨oror第第4 4颈椎水平颈椎水平锁骨上窝（锁骨下动脉）锁骨上窝（锁骨下动脉）眼眶部（眼动脉）眼眶部（眼动脉）头后部下方（椎动脉）头后部下方（椎动脉）8 缺血性脑血管病血管内治疗手册9 10 11121314备皮备皮更换手术衣更换手术衣建立静脉留置通道建立静脉留置通道术前将检查资料（术前将检查资料（CT、MRI等）带等）带到导管室到导管室 1516器材器材穿刺器械：穿刺针、血管短鞘（穿刺器械：穿刺针、血管短鞘（4-6F）、短导）、短导丝、刀片、丝、刀片、 注射器（注射器（ 5ml

2、、10m1各各 1支）支）造影器械：造影器械： 超滑导丝超滑导丝 0.035/150cm、高压注射、高压注射器、造影管器、造影管(Pigtail、Headhunter、 Simmons)、10m1注射器注射器1支支 、2个三通接头、个三通接头、1个个Y型阀型阀、输液导管及造影连接管各、输液导管及造影连接管各1付付所有器械必须用肝素生理盐水冲洗，导管及鞘所有器械必须用肝素生理盐水冲洗，导管及鞘在进入血管前必须充分冲洗排气在进入血管前必须充分冲洗排气 17药品：药品： 18消毒消毒 19消毒消毒 2021 22 23 24252627282930313233343536373839 40主动脉弓

3、无名动脉 左侧锁骨下动脉 右锁骨下动脉右颈总动脉左颈总动脉右颈内动脉左颈内动脉右椎动脉左椎动脉4142434445沿导丝将导管送入颈总动脉近端沿导丝将导管送入颈总动脉近端回撤导丝，回抽后用肝素生理盐水冲洗导管回撤导丝，回抽后用肝素生理盐水冲洗导管调整视野调整视野 颅外：正位：脊柱位于屏幕正中颅外：正位：脊柱位于屏幕正中 侧位：第三颈椎椎体位于屏幕正中侧位：第三颈椎椎体位于屏幕正中 颅内：正位头位：头颅居中，上界平颅盖骨颅内：正位头位：头颅居中，上界平颅盖骨 侧位：上界平颅盖骨，左界平额骨前部侧位：上界平颅盖骨，左界平额骨前部造影剂：流速造影剂：流速5ml/s, 总量总量8ml (超选超选4ml

4、/s, , 总量总量6ml )46观察内容观察内容 是否存在狭窄、闭塞及严重扭曲是否存在狭窄、闭塞及严重扭曲 侧支循环代偿情况侧支循环代偿情况 有无发育异常有无发育异常 是否存在动脉瘤、是否存在动脉瘤、AVM、血管夹层等、血管夹层等 47 注意事项注意事项勿随意将导管头送入颈外动脉及颈内动脉勿随意将导管头送入颈外动脉及颈内动脉勿将导丝头送入颈内动脉勿将导丝头送入颈内动脉可行多角度投射造影可行多角度投射造影48 49将导管沿导丝置于锁骨下动脉内椎动脉将导管沿导丝置于锁骨下动脉内椎动脉 开口处造影开口处造影回撤导丝，回抽后用肝素生理盐水冲洗回撤导丝，回抽后用肝素生理盐水冲洗 导管导管505152勿

5、随意将导管头送入椎动脉内勿随意将导管头送入椎动脉内若右锁骨下近端狭窄，可将导管置入头若右锁骨下近端狭窄，可将导管置入头 臂干行右前斜头位造影臂干行右前斜头位造影若考虑为偏心性狭窄，可行多角度投射若考虑为偏心性狭窄，可行多角度投射 造影造影53545556575859 Black9F601- PSI (max)2-French size3-Shaft length (usable)4-GW accept.61 simmons6263646566676869707172SAPPHIRE 研究研究73ANGIOGUARD血栓保护装置血栓保护装置Cordis PRECISE支架支架74CONSENSU

6、S一致同意一致同意RANDOMIZED, PROSPECTIVE随机，前瞻性随机，前瞻性310 (12 month)Stenting支架组支架组=159 / CEA=151STENTREGISTRY支架注册支架注册407SURGICAL REFUSAL外科拒绝外科拒绝SURGICALREGISTRY外科注册外科注册7INTERVENTIONALREFUSAL介入拒绝介入拒绝 75EventsStent (159 pst)CEA (151 pts)p ValueStent (159 pts)CEA (151 pts)p ValueDeath0.6%2.0%0.366.9%12.6%0.12Str

7、oke3.1%3.3% 0.995.7%7.3%0.66Major ipsilateral0.0%1.3%0.240.0%3.3%0.03Major Non-Ipsilateral0.6%0.7% 0.990.6%0.7% 0.99Minor Ipsilateral2.5%0.7%0.373.8%2.0%0.5Minor Non -Ipsilateral0.6%0.7 0.991.9%2.0% 0.99MI (Q or NQ)1.9%6.6%0.052.5%7.9%0.04Q-Wave MI0.0%1.3%0.240.0%1.3%0.24Non-Q Wave MI1.9%5.3%0.132.5

8、%6.6%0.1Death / Stroke3.8%4.6%0.78Death / Stroke / MI4.4%9.9%0.0811.9%19.9%0.06MAE withoutnon-neuro Death 30 days5.7%12.6% 30 days5.0%7.3%0.48Randomized Patients 12-Month EventsRandomized Patients 30-Day EventsSAPPHIRE (high-risk patients) 30 days and 12 months results SAPPHIRE (high-risk patients)

9、30 days and 12 month results“Stented patients are now 12 months out from treatment, and their MAE rate continue to be as good as, and in many ways better than, those for the surgically treated group.”接受治疗接受治疗12个月后，支架组病人不良事件的发生率相当于，甚至在很多方面，优于手术治疗组。个月后，支架组病人不良事件的发生率相当于，甚至在很多方面，优于手术治疗组。76Overall MAE ra

10、te总体主要不良事件发生率总体主要不良事件发生率11.9% vs. 19.9% : difference 显著差异显著差异, p = 0.06Death rate 死亡率死亡率6.9% vs. 12.6%: double number of patients died in the CEA arm 外科组死亡人数比支架组多一倍外科组死亡人数比支架组多一倍Stroke rate中风发生率中风发生率 5.7% vs. 7.3%: 30% more patients experienced a stroke in the CEA arm 外科组至少发生一次中风的病人数比支架组多外科组至少发生一次中风

11、的病人数比支架组多30%Major Ipsilateral Stroke rate主要同侧大中风发生率主要同侧大中风发生率 0.0% vs. 3.3% was significant higher in CEA 外科组显著高于支架组，外科组显著高于支架组，p = 0.03MI (Q or non Q) rate 心梗发生率心梗发生率2.5% vs. 7.9%: patients got 3 times more MI in the CEA arm 外科组发生心梗的病人数比支架组多三倍以上外科组发生心梗的病人数比支架组多三倍以上Outcome of cranial nerve injury (3

12、0 days) 30天内颅神经损伤的天内颅神经损伤的发生率发生率 0.0% vs. 5.3%: was significant for CEA arm外科组显著高于支架组，外科组显著高于支架组，p 0.0177787980CAS(n-1262)CEA(n=1240)年龄6969女性3634无症状性4747高血压8686糖尿病3030血脂异常8285目前吸烟2626心血管病4043平均收缩压mmHg14214170%狭窄的例数8587症状性狭窄发病天数202581 HR=1.11 95%CI 0.81-1.51 P=0.518283 HR=1.18 95%CI 0.82-1.68 P=0.388

13、4 卒中 HR=1.79 95% CI 1.14-2.82 P=0.01 心梗 HR=1.35 95% CI 0.54-3.36 P=0.5285 HR=0.07 95% CI 0.02-0.18 P0.000186 HR=0.94 95% CI 0.50-1.76 P=0.8587结论88899091929394 9550100 U/kg)96979899100球扩式支架球扩式支架Palmaz Stent (Cordis)自膨式支架自膨式支架Carotid Wallstent (Boston Scientific)PRECISE (Cordis)Protg (ev3) (Abbott）101

14、雕刻支架雕刻支架 编织支架编织支架102优点优点支撑力更大支撑力更大, ,不易塌陷不易塌陷柔韧性更强，表面光滑，易于球囊通过柔韧性更强，表面光滑，易于球囊通过网孔密集，限制斑块脱落网孔密集，限制斑块脱落可重新定位、再次释放可重新定位、再次释放103不足不足短缩、不易精确定位短缩、不易精确定位拉伸颈动脉、上端扭曲、成角拉伸颈动脉、上端扭曲、成角凹凸不平处贴壁欠佳凹凸不平处贴壁欠佳104优点优点顺应性好，适应不同形状而不造成血管顺应性好，适应不同形状而不造成血管强直强直贴壁性好，不易造成死腔贴壁性好，不易造成死腔基本无缩短，定位和选择长度较精确基本无缩短，定位和选择长度较精确不足不足后扩时有连接点

15、断裂的风险后扩时有连接点断裂的风险105106107108109110111External Carotid ArteryInternal Carotid ArteryCommon Carotid Artery112External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryTerumo guidewire0.035”100cmHeadhunter5F Tempo200cmINTRODUCE GUIDEWIRE AND INTRODUCER SHEATH113External Carotid ArteryInternal

16、 Carotid ArteryCommon Carotid ArteryTerumo guidewire0.035”100cmHeadhunter5F Tempo200cmINTRODUCE GUIDEWIRE AND INTRODUCER SHEATH114External Carotid ArteryInternal Carotid ArteryCommon Carotid ArterySELECTIVE CATHETHETERISATION OF ECATerumo guidewire0.035”100cmHeadhunter5F Tempo200cm115External Caroti

17、d ArteryInternal Carotid ArteryCommon Carotid ArteryHeadhunter5F Tempo200cmEXCHANGEGUIDEWIRETerumo guidewire0.035”100cm116External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryHeadhunter5F Tempo200cmEXCHANGEGUIDEWIRE117External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryH

18、eadhunter5F Tempo200cmEXCHANGEGUIDEWIREAmplatz Emerald0.035”260cm118External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryAmplatz Emerald0.035”260cmEXCHANGEINTRODUCER SHEATH119External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryAmplatz Emerald0.035”260cmBrite Tip Sheath7F

19、80cmEXCHANGEINTRODUCER SHEATH120External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cmREMOVE GUIDEWIRE121Carotid Artery Disease :Carotid Angioplasty - ProcedureHints122External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cmINTRODUC

20、E PROTECTION DEVICE123External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryAngioguard0.014”300cmBrite Tip Sheath7F80cmINTRODUCE PROTECTION DEVICE124Angioguard Device :Delivery Sheath Covering Filter125External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F

21、80cmCROSS LESION WITH PROTECTION DEVICEAngioguard0.014”300cm126External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cmCROSS LESION WITH PROTECTION DEVICEAngioguard0.014”300cm127External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryDEPLOYMENT PROTECTION

22、DEVICEBrite Tip Sheath7F80cmAngioguard0.014”300cm128Angioguard Device :Filter Deployed129Carotid Artery Disease :Carotid Angioplasty - ProcedureHints130External Carotid ArteryInternal Carotid ArteryCommon Carotid ArterySTENT DEPLOYMENT Smart Carotid stent7-8mm30-40mmBrite Tip Sheath7F80cmAngioguard0

23、.014”300cm131External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmSTENT DEPLOYMENTAngioguard0.014”300cm132External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmANGIO

24、GRAPHICCONTROLAngioguard0.014”300cm133External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014”300cm134External Carotid ArteryInternal Carotid ArteryCommon Carotid Artery Savvy balloon5-6mm30-40mmBrite

25、 Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmPOSTDILATATIONAngioguard0.014”300cm135External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmPOSTDILATATIONAngioguard0.014”300cm Savvy balloon5-6mm30-40mm136External Carotid ArteryInter

26、nal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014”300cm137External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014”300cm138

27、External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryRETRIEVAL PROTECTION DEVICEBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmAngioguard0.014”300cm139External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmRETRIEV

28、AL PROTECTION DEVICEAngioguard0.014”300cm140Angioguard Device :Capture Sheath Retrieving Filter141External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmRETRIEVAL PROTECTION DEVICEAngioguard0.014”300cm142Angioguard Device :Retrieved B

29、asket143External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmANGIOGRAPHICCONTROL144External Carotid ArteryInternal Carotid ArteryCommon Carotid ArteryBrite Tip Sheath7F80cm Smart Carotid stent7-8mm30-40mmANGIOGRAPHICCONTROL145External Carotid ArteryInternal Carotid ArteryCommon Carotid Artery Smart Carotid stent7-8mm30-40mm146147