指引导管的选择和操作技术课件.ppt

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1、Li Yue,M.D.,The First Affiliated Hospital of Harbin Medical University,指引导管的选择和操作技术,3000 B.C.Egyptians perform bladder catheterizations using metal pipes.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,1711 Hales conduct

2、s the first cardiac catheterization of a horse using brass pipes,a glass tube and the trachea of a goose.,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.,1967年，Melvin P.Judkins设计冠脉造影专用导管,1977 Gruentzig,performs first cath lab PTCA on awake pati

3、ent in Zurich;starting with this case,all PTCA data is entered into a worldwide registry,输送各种介入器械 支持作用 注射造影剂及各种相关治疗、抢救药物 血流动力学监测,导引导管功能,导引导管选择要求,创伤小 同轴性好 支撑力好 足够管腔直径,柔软的可视头端（安全区）柔软的同轴段（柔软区或传送区）中等硬度的抗折段（支撑区）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

4、（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,支撑力 内径大小 顺应性 扭控性 抗折性,导引导管性能参数,钙化,迂曲,闭塞,导引导管支撑力,被动支撑（通过导管结构和外形获得支持）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 Vista,Medtronic Launcher,Boston Mach 1,2 X 2编织:2根圆钢丝在另2根圆钢丝之上,Bo

5、ston Runway,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。,JL4.0,SL4.0,EBU3.75,4、导管与主动脉夹角 越接近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,JL4.0,Downsizing from(6F)to(5F)after rotational atherectomy via tranradial approach with safe deep cannulation may be a solution to compass lacks of support and

6、 to lead to cross the calcified lesions and deployment of the stent.,Deep seating,Cardiovascular Resvacularization Medicine,2011,1.5 mm bur,6F EBU,Deep seating,5F EBU,深插方法（避免开口部损伤）,内径大小,MedtronicLauncher,大腔导管,Terumo,Full 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

7、、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 Tip,Extra Backup类导引导管,JL基础上改进头端直线形，更好同轴第二弯曲与左冠开口对侧主动脉壁贴合更长选择XB应比JL小0.5,XB LAD,XB C,支撑力较JL增加50%,形状介于XB 和XBLAD之间 操作方便,弧度较大的第二弯曲紧靠对侧主动脉壁。,Medtronic EBU,Boston left specialty curves,LAD通常选Q curve 4,通

8、常选Voda 3.5,支撑力更好,XBRCA,ART,MAC(Multi Aortic Curve),对侧壁提供后座力支持力介于JR和 Amplatz之间与BSC的ART或MDT 的MAC相似,头端直线形，通过对侧壁提供额外后座力同时可深插适合开口向下RCA与BSC的Voda Right或MDT的ECR相似。,XBR,ECR,Medtronic RBU（Right back up),对侧壁支撑适合开口平行或 向下RCA通常插入10-12mm介于MAC和 Amplatz之间通常使用RBU3.5,MAC,Amplatz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

9、.75、AL1、AL1.5、AL2、AL3、AL4 根据R段的长短分为AR1、AR2,第二弯曲与冠状窦及对侧壁贴合，多点支撑AL2用于LCAAL1、0.75用于RCA,AL,AR,第二弯曲小限制器械通过支撑力弱仅用于“牧羊钩”样RCA,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,短头,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

10、最低 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。,MP,向上开口 RCA 和桥血管 支撑力介于JR和Amplatz之间 第一个弯较直，便于输送器械 HSII 用于正常直径主动脉,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,JL4 开口高或主动脉根部小，可用JL3.5 LM短，用短头 扭曲、钙化、闭塞用Amplatz或Extra backup,RCA导引导管选择,JR4 开口向上，用Amplatz

11、或Hockey stick,JL 3.5,开口向上或水平,冠脉起源异常导管选择,左冠口起源于右冠窦，选JR4或Amplatz 右冠起源于左冠窦，选Amplatz或JL 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进行各种弯曲、形状的设计如3DRC(Mdetronic)导管。,Sherpa NX Active 3DRCA,螺旋状尾端 第2、3弯顶在主动脉壁提供强支撑 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,静脉桥血管导管选择常凭经验 CTA或升主动脉造影有帮助,LCB(Left

12、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开口起源于右冠桥上侧方，选择JR、LCB、Hockey Stick、Amplatz或MP。,开口如无明显成角，用JR4或LCB明显成角者用专用导管（IMA)可选择左侧桡动脉入路,LIMA桥血管,IMA,LCB IMA JR,需要更大支持力怎么办,？,更大直径 深插（头端较直、较细导管更易深插，且可减少对冠脉损伤）子母导管,Heartrail II(Terumo

13、,Japan)long(120 cm)5 Fr catheter(13 cm very soft end portion)Absence of curve and the flexibility of its tip permit the“child”catheter coaxial with the target vessel,minimizing the risk of dissection.,5 in 6 guiding catheter technique,Inner catheter,Filled with water that was kept at 37C,5 mm/s,Swit

14、ching to 5-in-6 system,Coronary artery injury Deep-vessel engagement can be facilitated by passage of a balloon catheter Air embolism,7F 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,Rapid exchange Flexible yello

15、w 20 cm straight extension connected to a stainless-steel push tube Results in an I.D.approximately 1F size smaller available in three sizes:6F,7F and 8F,Not recommend its use in target vessels of 2.5 mm diameter,Softer tip and hydrophilic coating on inside and outside.5-Fr ST01 has the coating only

16、 on the inside.,Catheterization and Cardiovascular Interventions 76:919923(2010),(Terumo,Japan),KIWAMI ST01,Backup support of GC,Circ Cardiovasc Interv.2011 Apr 1;4(2):155-61,5-in-6 system Extending 3 cm,the backup support 7F GC,4-in-6 systemExtending 5 cm,the backup support signicantly increased bu

17、t still 7F GC,Trackability of GC,Using balloon-anchoring technique 5F child catheter could be advanced to 13.0 cm,whereas the 4F child catheter could be advanced to 15.0 cm(P0.005).,Provided 90%success rate for 51 lesions in which conventional techniques had failed.,Success may be contributed,in mos

18、t part,by the trackability of the 4F child catheter.Does not usually compromise the coronary flow.,Peripheral balloon anchor method Balloon used for predilatation to the most distal portion of the lesion.Inated and used as the anchor KIWAMI is inserted slowly toward inated anchoring balloon.Not to d

19、ilate the balloon at the healthy portion,Cypher(3.0 18 mm),5-Fr ST01 allows any BMS and DES KIWAMI effective for stents with a diameter up to 3.0 mm for Cypher and TAXUS Liberte,3.5 mm for Endeavor Most of BMS can be deployed using KIWAMI except DRIVER(Medtronic),经桡动脉PCI导引导管选择,和经股动脉基本原则一致 右侧桡动脉导管型号比

20、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 TFI with a backup(EBU/XB)type catheter.,J Invasive Cardiol.2005 Dec;17(12):636-41,the Ikari L(IL)catheter generated a similar backup force between TRI and TFI.,特有的第1

21、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,JL,IL,JR,IR,Fajadet导管,JFL,JFR,(France),Long tip设计提供良好支撑力和同轴性。,MUTA-L/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

22、用节省时间,KIMNY Curve,Radial 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,Radial artery diameter,radial artery internal diameter/sheath external diameter,4%in patients with ratio 1,13%in patients with ratio 1,The dosage of he

23、parin,the diameter of radial artery and the post-procedure compression pressure and time were independent risk factors for RAO,Cathet Cardiovasc Diagn 1997;40:156158,Radial artery diameter,6F sheath external diameter=2.62mm,Strategy selection(6F),MADS classification Y.Louvard,CCVI pending,Guiding ca

24、theter selection Large inner diameter Launcher(Medtronic)and Heartrail II(Terumo)Good back-up support LCA:EBU,BL,XB,Voda,Q-curve,Ikari L RCA:AL-0.75/1,AR-1/2,JR,JL3.5,XBRCA,Radial artery diameter,5F sheath external diameter=2.29mm,0.010-inch guidewire and compatible balloon catheter,IKAZUCHI-X(KANEK

25、A Medix Corporation Osaka,Japan)Double balloon ination with a 5-Fr guiding catheter Triple balloon ination with a 6-Fr guiding catheter,6F,Comparison of profile among balloon catheter systems,Coil-type guidewires:Athlete Slender 01(Japan Life Line,Tokyo,Japan)Decillion FL,and Decillion MD(Asahi inte

26、cc,Nagoya,Japan)Hydrocoated 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 diameter,

27、The frequency of this ratio(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 catheter,Sheathless GC system(Asahi Intecc,Japan)hydrophilic GC+central dilator.,The outer diameter of the 6.5 F sheathless GC(2.16 mm)is smaller than

28、 a 5 F sheath(2.29 mm).The outer diameter of the 7.5 F sheathless GC(2.49 mm)is less than that of a 6 F sheath(2.62 mm).,Thicker 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 w

29、as exchanged for the sheathless catheter over a standard 150 cm J-tipped 0.035-inch(Terumo,Japan)wire.,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 dressing,Disadvantage

30、 The shapes of catheters were slightly diferent from those of conventional catheters.This system requires more time to assemble Extra care should be exercised when coronary intubation is attempted to prevent catheter tip induced coronary artery dissection.,Performed PCI in 100 consecutive cases usin

31、g 6.5 Fr sheathless guides,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.Radial spasm rate of 5%using 6.5 Fr catheters,1.1%with 5 Fr systems,22%using 6 Fr Sheaths.,UK,Severe artery spasm:making manipulation difficult,Uppe

32、r limb artery spasm High origin of radial artery Accessory brachial artery,The 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 Inniti Diagnostic Catheter(Cordis Corporation,Miami,FL)over a 0.035 inch J-tip guidewire,USA,Catheterization 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,Thanks!,