指引导管的选择和操作技术课件.ppt

1、The First Affiliated Hospital of Harbin Medical University指引导管的选择和操作技术u 3000 B.C.Egyptians perform bladder catheterizations using metal pipes.u 400 B.C.Catheters fashioned from hollow reeds and pipes are used in cadavers to study the function of cardiac valves.人类使用导管的历史u 1711 Hales conducts the firs

2、t cardiac catheterization of a horse using brass pipes,a glass tube and the trachea of a goose.u 1929年，德国外科医生Werner Forssmann将一根 导尿管插入自己心脏，这是插入人体心脏的第 一根导管。Nobel Prize，1956 For his pioneering efforts.u 1958 The diagnostic coronary angiogram the key to selective imaging of the heart is discovered by M

3、ason Sones.u1964 Transluminal Angioplasty,the concept of remodeling the artery,is introduced by Charles T.Dotter.u1967年，Melvin P.Judkins设计冠脉造影专用导管u 1977 Gruentzig,performs first cath lab PTCA on awake patient in Zurich;starting with this case,all PTCA data is entered into a worldwide registry u 输送各种

4、介入器械u 支持作用 u 注射造影剂及各种相关治疗、抢救药物u 血流动力学监测导引导管功能导引导管选择要求u 创伤小u 同轴性好u 支撑力好u 足够管腔直径u 柔软的可视头端（安全区）u 柔软的同轴段（柔软区或传送区）u 中等硬度的抗折段（支撑区）u 牢固的扭控段（扭控区或推送区）导引导管节段导引导管构造外 层 聚乙烯塑料 决定导管形状、硬度和与血管内膜间的摩擦力中 层 12-16根钢丝编织成，使导管具备抗折断、抗扭曲、顺应性和弹性（不同厂家编织方式不同）内 层 尼龙聚四氟乙烯（PTFE）涂层，减少导丝、球囊、支架与导管内腔间摩擦力，抗血栓u 支撑力u 内径大小u 顺应性u 扭控性u 抗折性导

5、引导管性能参数钙化迂曲闭塞导引导管支撑力u 被动支撑（通过导管结构和外形获得支持）u 主动支撑（术者操作获得）被动支撑力 取决于直径、结构、导管与主动脉壁接触面积和夹角。1、直径越大、支持力越强。2、中层钢丝编织方式。一圆一扁钢丝编织成的相对较硬、支持力强；扁平钢丝编织成的导管柔软、支持力弱。Cordis VistaMedtronic LauncherBoston Mach 1u 2 X 2编织:2根圆钢丝在另2根圆钢丝之上 Boston Runwayu 4 X 2编织:抗折性、扭控性更好3、导管与主动脉内壁接触面积越大，支持力越强。JL4.0SL4.0EBU3.754、导管与主动脉夹角 越接

6、近90度，支持力越强，夹角越小，越差。主动支撑力Deep seating使其与主动脉夹角更趋于90度JL4.0Downsizing from(6F)to(5F)after rotational atherectomy via tranradial approach with safe deep cannulation may be a solution to compass lacks of support and to lead to cross the calcified lesions and deployment of the stent.Deep seatingCardiovascu

7、lar Resvacularization Medicine,20111.5 mm bur6F EBUDeep seating5F EBU深插方法（避免开口部损伤）内径大小MedtronicLauncher大腔导管大腔导管TerumoFull Wall技术 指导管在体内被旋转、操控的能力。决定于钢丝编织方式和polymer特性。扭控力、抗折力导引导管类型Judkins导管（操作简单，适用于简单、中等难度病变）常用导引导管点状被动支撑不与动脉壁接触源于导管本身结构Judkins导管型号短头导管正常短头导管正常XB 3.5支撑力较JL增加67%Cordis Vista Brite TipExtra

8、 Backup类导引导管uJL基础上改进u头端直线形，更好同轴u第二弯曲与左冠开口对侧主动脉壁贴合更长u选择XB应比JL小0.5XB LADXB C支撑力较JL增加50%u 形状介于XB 和XBLAD之间u 操作方便弧度较大的第二弯曲紧靠对侧主动脉壁。Medtronic EBUBoston left specialty curvesLAD通常选Q curve 4通常选Voda 3.5支撑力更好XBRCAARTMAC(Multi Aortic Curve)u对侧壁提供后座力u支持力介于JR和 Amplatz之间u与BSC的ART或MDT 的MAC相似u头端直线形，通过对侧壁提供额外后座力同时可深

9、插u适合开口向下RCAu与BSC的Voda Right或MDT的ECR相似。XBRECRMedtronic RBU（Right back up)u对侧壁支撑u适合开口平行或 向下RCAu通常插入10-12mmu介于MAC和 Amplatz之间u通常使用RBU3.5MACAmplatz导管 良好的同轴和被动支持力，可用于多数起源异常冠状动脉。根据L段长短分为AL0.75、AL1、AL1.5、AL2、AL3、AL4 根据R段的长短分为AR1、AR2u第二弯曲与冠状窦及对侧壁贴合，多点支撑uAL2用于LCAuAL1、0.75用于RCAALARu第二弯曲小u限制器械通过u支撑力弱u仅用于“牧羊钩”样R

10、CA进出导管时需注意：1、当Amplatz导管的“L”或“R”段位于冠状动脉开口水平线上方时，可直接撤出或深插导管。2、当“L”或“R”段位于冠状动脉开口水平线下方时，切忌直接后撤导管，应推送导管，以底部为支撑点，使导管尖端后退，离开冠脉开口，再旋转导管。推送旋转短头Amplatz导管标准标准短头短头u 刮伤主动脉窦情况 大大降低，造成靶血 管撕裂、夹层可能降 到最低u 入冠不深，几乎没有嵌顿现象、其他导引导管 主要适用于向下的冠脉开口，可用于LCA和RCA。MPu 向上开口 RCA 和桥血管u 支撑力介于JR和Amplatz之间u 第一个弯较直，便于输送器械 u HSII 用于正常直径主动脉

11、,HSI 用于窄主动脉 HSIII 用于宽主动脉Medtronic主要用于开口向上血管导引导管选择同轴同轴不良引起冠脉开口损伤型号选择开口高，选小号开口低，选大号LCA导引导管选择u JL4u 开口高或主动脉根部小，可用JL3.5u LM短，用短头u 扭曲、钙化、闭塞用Amplatz或Extra backupRCA导引导管选择u JR4u 开口向上，用Amplatz或Hockey stickJL 3.5开口向上或水平冠脉起源异常导管选择u 左冠口起源于右冠窦，选JR4或Amplatzu 右冠起源于左冠窦，选Amplatz或JLu 升主动脉造影或CTA有帮助LCA起源右冠窦 三维导管在不同轴向上

12、进行各种弯曲、形状的设计如3DRC(Mdetronic)导管。Sherpa NX Active 3DRCAu 螺旋状尾端u 第2、3弯顶在主动脉壁提供强支撑u 0.032inch导丝引导进入后顺时针或逆时针旋转AP-Cranial见RCA起源于左窦LAO见RCA起源异常桥血管导引导管选择u 静脉桥血管导管选择常凭经验u CTA或升主动脉造影有帮助LCB(Left coronary bypass)/RCB(Right coronary bypass)导引导管右冠桥血管 右冠桥血管多起源于主动脉根部上方2-3cm的前壁，开口多向下，选择MP、Amplatz或RCB。左冠桥血管 前降支和回旋支桥血管

13、开口起源于右冠桥上侧方，选择JR、LCB、Hockey Stick、Amplatz或MP。u开口如无明显成角，用JR4或LCBu明显成角者用专用导管（IMA)u可选择左侧桡动脉入路LIMA桥血管IMALCB IMA JR需要更大支持力怎么办？u 更大直径u 深插 （头端较直、较细导管更易深插，且可减少对冠脉损伤）u 子母导管u Heartrail II(Terumo,Japan)long(120 cm)5 Fr catheter(13 cm very soft end portion)u Absence of curve and the flexibility of its tip permi

14、t the “child”catheter coaxial with the target vessel,minimizing the risk of dissection.5 in 6 guiding catheter technique Inner catheterFilled with water that was kept at 37C5 mm/sSwitching to 5-in-6 system u Coronary artery injury Deep-vessel engagement can be facilitated by passage of a balloon cat

15、heter u Air embolism7F AL-1;3.5mm balloon(Goodman,Japan)The lumen size of the aspiration catheter as the size of SES is limited to 3.0 mm.GuideLiner cath u Rapid exchange u Flexible yellow 20 cm straight extension connected to a stainless-steel push tubeu Results in an I.D.approximately 1F size smal

16、ler u available in three sizes:6F,7F and 8F Not recommend its use in target vessels of 7F GC4-in-6 systemExtending 5 cm,the backup support significantly increased but still 7F GCTrackability of GCu Using balloon-anchoring techniqueu 5F child catheter could be advanced to 13.0 cm,whereas the 4F child

17、 catheter could be advanced to 15.0 cm (P90%success rate for 51 lesions in which conventional techniques had failed.u Success may be contributed,in most part,by the trackability of the 4F child catheter.u Does not usually compromise the coronary flow.Peripheral balloon anchor method u Balloon used f

18、or predilatation to the most distal portion of the lesion.u Inflated and used as the anchoru KIWAMI is inserted slowly toward inflated anchoring balloon.u Not to dilate the balloon at the healthy portionCypher(3.0 18 mm)u 5-Fr ST01 allows any BMS and DESu KIWAMI effective for stents with a diameter

19、up to 3.0 mm for Cypher and TAXUS Liberte,3.5 mm for Endeavoru Most of BMS can be deployed using KIWAMI except DRIVER(Medtronic)经桡动脉PCI导引导管选择u 和经股动脉基本原则一致u 右侧桡动脉导管型号比股动脉小半号，左侧和股动脉相同Comparing the backup force between TFI and TRIit was found to be 60%greater in TFI with a JL catheter,and 8%greater in

20、TFI with a backup(EBU/XB)type catheter.J Invasive Cardiol.2005 Dec;17(12):636-41the Ikari L(IL)catheter generated a similar backup force between TRI and TFI.特有的第1弯曲利用右锁骨下动脉和无名动脉间夹角提供强支撑力J Invasive Cardiol.2005 Dec;17(12):636-41经桡动脉PCI专用导引导管JLILJRIRFajadet导管JFLJFR(France)Long tip设计提供良好支撑力和同轴性。MUTA-L/

21、R MUTA L导管和JL导管相似，但支撑力比后者强，MUTA R导管弯曲是一种三维设计，有MR2和MR3两种，MR2最常使用。适合右侧桡动脉入路，可用于左右冠和静脉桥，较Judkins导管同轴性和主、被动支撑力好，易于操控，但较long-tip导管支撑力差。左右共用导引导管AMI病变,直接使用节省时间KIMNY CurveRadial Brachial(Cordis)3个弯度设计；适于水平或开口向下病变可以深插；左右桡动脉入路均可。Radial Runway 适合右侧桡动脉入路，可用于左右冠和静脉桥，结构特点类似与KIMNY。分为标准、短头和高位开口头。Barbeau导管Male（mm）Fe

22、male（mm）国外3.10.6 2.80.6 魏盟2.70.4 2.30.4 贾三庆2.650.60 2.200.49 Radial artery diameterradial artery internal diameter/sheath external diameter4%in patients with ratio 113%in patients with ratio 1uThe dosage of heparin,the diameter of radial artery and the post-procedure compression pressure and time we

23、re independent risk factors for RAOCathet Cardiovasc Diagn 1997;40:156158 Radial artery diameter6F sheath external diameter=2.62mmain prox.firstMain ccross side firstistal firstide branch firstExtended VSkirtPM stentingMB stenting across SB MB stenting+kissingMB stenting+SB balloonElectiveT stenting

24、InternalcrushCulotteTAPDM stentingProvisionalSKSVstentingSKSTrouser legsand seatSB ostial stentingSB minicrushSB crushSyst.T StentingMinicrushCrushAfterballoon2 stents3 stents1st stentSkirt+DMSkirt+SBStrategy selection(6F)MADS classification Y.Louvard,CCVI pendingGuiding catheter selectionu Large in

25、ner diameter Launcher(Medtronic)and Heartrail II (Terumo)u Good back-up support LCA:EBU,BL,XB,Voda,Q-curve,Ikari L RCA:AL-0.75/1,AR-1/2,JR,JL3.5,XBRCARadial artery diameter5F sheath external diameter=2.29mm0.010-inch guidewire and compatible balloon catheter,IKAZUCHI-X(KANEKA Medix Corporation Osaka

26、,Japan)Double balloon inflation with a 5-Fr guiding catheter Triple balloon inflation with a 6-Fr guiding catheter6FComparison of profile among balloon catheter systemsCoil-type guidewires:Athlete Slender 01(Japan Life Line,Tokyo,Japan)Decillion FL,and Decillion MD (Asahi intecc,Nagoya,Japan)Hydroco

27、ated guidewire：the Athlete Eel Slender(JapanLife Line,Tokyo,Japan)IKAZUCHI-X Semi-compliant balloon Diameters from 1.5 to 3.5 mm Length is 9 mm for a 1.5 mm diameter and 15 mm for other diameters Nominal pressure is 8 atm,rated burst pressure is 14 atm.Radial artery diameterThe frequency of this rat

28、io(1.0)for 7 and 8 Fr sheaths was 71.5%and 44.9%in male patients and 40.3%and 24.0%in female patients.7F sheath and guiding catheterSheathless GC system (Asahi Intecc,Japan)hydrophilic GC +central dilator.uThe outer diameter of the 6.5 F sheathless GC(2.16 mm)is smaller than a 5 F sheath(2.29 mm).Th

29、e outer diameter of the 7.5 F sheathless GC(2.49 mm)is less than that of a 6 F sheath(2.62 mm).uThicker than conventional guide catheters due to an addition layer of steel braiding and the hydrophilic coating,aids backup support.After the diagnostic angiography,the sheath was exchanged for the sheat

30、hless catheter over a standard 150 cm J-tipped 0.035-inch(Terumo,Japan)wire.u Sheathless GCs slide easily within vessels due to the hydrophilic coating,disengagement of the catheter could happen in cases requiring good guiding support.Tegaderm adhesive dressingDisadvantageu The shapes of catheters w

31、ere slightly diferent from those of conventional catheters.uThis system requires more time to assemble u Extra care should be exercised when coronary intubation is attempted to prevent catheter tip induced coronary artery dissection.Performed PCI in 100 consecutive cases using 6.5 Fr sheathless guid

32、esu Radial occlusion rate of 2%using 6.5 Fr catheters,0%with 4 Fr systems and 17%with 5 Fr systems,611%with 6 Fr guide catheters.u Radial spasm rate of 5%using 6.5 Fr catheters,1.1%with 5 Fr systems,22%using 6 Fr Sheaths.UKSevere artery spasm:making manipulation difficult Upper limb artery spasm Hig

33、h origin of radial artery Accessory brachial arteryThe conventional GC did not pass through bifurcation high origin radial artery.6.5 Fr sheathLess GC passed through“Pseudo-taper”Guide catheters inserted with a long(125 cm)5 or 6 Fr Infiniti Diagnostic Catheter(Cordis Corporation,Miami,FL)over a 0.035 inch J-tip guidewireUSACatheterization and Cardiovascular Interventions 76:911916(2010)导引导管手工塑型“钓鱼”技术先送入导丝甚至球囊或微导管，再送入导引导管8F AL 1 guiding catheter(arrow)5F multipurpose inner catheter(arrow head)coaxial double catheter 300 cm-long BMWBuddy wire