经桡动脉DSA

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,经桡动脉入路行全脑血管造影,1989,年加拿大医生,Campeau,首先报道应用,桡动脉穿刺进行冠状动脉造影取得成功，在心,血管介入诊疗中逐渐发展 。,优点,：表浅，止血容易，并发症少；,无需长时间卧床，缩短留院时间，节省费用；,患者易接受,桡动脉穿刺技巧,和,血管动脉造影技术。,适应症（,Indications,）,(a),随诊（,imaging follow-up,）,;,(b),门诊患者（,cerebral angiography on an out-patient basis,）,;,(c),较差的股动脉入路 （,poor femoral access,）,;,(d),应用抗血小板或抗凝治疗患者（,patients on antiplatelets or anticoagulation therapy,）,禁忌症,桡尺动脉侧支循环不良,Allen,试验,5,秒,其它：,桡动脉难触及；身材矮小女性桡动脉较细；,头臂干或锁骨下动脉严重疾病；,穿刺部位严重瘢痕等,桡动脉血氧监测,The arterial waveform and arterial O2 saturation (SaO2) were checked via a pulse oximeter applied to the thumb.,桡动脉穿刺技术,桡动脉解剖定位,桡动脉穿刺和置入动脉鞘操作难点,较细小，易痉挛，不易穿刺成功 ；,周围支撑组织少，有高血压和动脉样硬化时易滑动；,有分支和走向解剖变异。,穿刺前仔细扪诊桡动脉了解其走向、血管弹性、搏动情况,Allen,试验或桡动脉血氧监测,开始注射麻药不宜过多，,0.3-0.5ml,皮下浸润 ；,专用的,桡动脉穿刺针,：,Cordis,公司的空心钢针和,Terumo,公司的套管钢针,21-G,穿刺成功后退针应,缓慢,；,导丝和动脉鞘管进入时应无阻力，若稍有阻力，则应在透视下操作切忌粗暴推送 。,穿刺点选择,桡动脉,过于靠近远端，误入分支血管；,过于靠近近心端，增加穿刺的难度,穿刺失败，向近心端移重新选择穿刺点。,穿刺点一般在,桡骨茎突近端,1cm,处：走行较直、相对表浅，穿刺容易成功，分支相对较少，穿刺误入分支血管的几率较小。,但在少数桡动脉迂曲、变异，穿刺点的选择应因人而异。理想的穿刺点应选择在,桡动脉走行较直且搏动明显的部位。,局麻,建议应用,“两步法”,给予局麻药物，即穿刺前皮下少量注射麻药，穿刺成功后在鞘管置入前再补充一定剂量的麻醉药物。但在注射麻醉药物时进针不宜过深，以免误伤桡动脉。,穿刺技巧,“,The first is the best ”,腕部垫高，腕关节处于,过伸状态,穿刺者左手指轻放于患者桡动脉搏动最强处，指示患者桡动脉的走行方向。,避免按压过度，会造成桡动脉远端的血流受阻，人为增加了穿刺的难度。,进针角度一般,30,45,，但对于血管较粗或较硬者，进针角度应稍大；而对于血管较细者进针角度应略小；,针尾部见回血，再前送穿刺针少许后，套管针穿刺者，应先退出针芯后再回撤套管，注意退出针芯时确保固定套管位置，至针尾部,喷血,后再送入导丝，不能有阻力。,如进针后未见针尾部回血，可用左手食指,判断此时穿刺针与桡动脉的位置关系,，再回撤穿刺针至皮下，调整针尖方向后再次进针。,送入导丝,穿刺针尾端,喷血,良好，固定针柄以确保穿刺针位置不动，同时右手送入导丝，动作应轻柔,遇到阻力应停止前送导丝，可部分回撤导丝后，改变穿刺针的角度或旋转穿刺针调整导丝的前进方向后再次试送导丝，切忌强行推送导丝，误伤小分支导致,前臂血肿,的发生。通常情况下要求前送导丝至少应达到尺骨鹰嘴水平后再沿送鞘管。,置入鞘管,置入鞘管前，需在穿刺部位补充麻醉药。动脉鞘管表面附有亲水涂层材料，降低鞘管送入时的摩擦力，防止桡动脉痉挛发生。,置入鞘管后一同撤出扩张管及导丝。如能经侧管顺利回血，可判定鞘管位于血管真腔，桡动脉穿刺成功。,A 5-F introducer sheath was inserted into the radial artery.,注意,动脉鞘连接生理盐水过多的冲洗，会导致动脉痉挛，应避免。,肝素,2000,3000IU,。,若出现痉挛，可注入,硝酸甘油（,150,250ug,）,或,维拉帕米（,150,250ug,）,。,桡动脉穿刺过程中常见的问题及处理,同一部位反复穿刺不成功,穿刺针刺入桡动脉，但穿刺针尾部血流不畅,穿刺针回血良好，但送入导丝时阻力较大,置入鞘管时阻力较大,穿刺不成功,未能刺中桡动脉：针对不同情况改变穿刺手法后进针。,例如：,较硬易于滚动的桡动脉，搏动很强，但难以刺中,选择裸针穿刺更具优势，加大进针角度和速度 ；,桡动脉较细、搏动较弱,选择套管针穿刺进入真腔的成功率高，小角度穿刺，缓慢进针 。,桡动脉走行迂曲,：更换穿刺点至走行较直部位后再行穿刺；,桡动脉发生痉挛,：桡动脉的搏动减弱甚至消失。盲目穿刺可能会进一步加重桡动脉痉挛，等桡动脉搏动恢复后再行穿刺；（应用解痉药）,穿刺局部形成血肿,：,应避开血肿部位后重新选择穿刺点。,穿刺针尾血流不畅或送入导丝阻力较大,针尖,斜面未完全进入,血管腔：针尖的位置可能位于前壁或后壁,调整穿刺针的深度和进针角度使针尖完全进入血管腔。,桡动脉痉挛,不喷血，,但导丝常可顺利前送，不会对桡动脉入路的建立带来太大的障碍。,进入分支,：调整穿刺针位置后仍无法顺利前送导丝常提示此种可能，穿刺点过于靠近腕部时多见，常需要向近心端前移穿刺部位后再次进针。,桡动脉迂曲,：透视下调整导丝的前进方向后再试行通过弯曲段血管，必要时可能需要更换穿刺部位。,共有并发症,穿刺部位出血、血肿及假性动脉瘤,动静脉瘘,动脉夹层、动脉血栓、闭塞和穿刺动脉远端栓塞,桡动脉途径相关独有并发症,桡动脉 特点：超声测定直径,:,平均,2.600.41 mm,82%,病人适合,5F,鞘管。,注意：老龄、高血压患者桡动脉迂曲，无名动脉与主动脉弓成锐角；,0.4%2%,右锁骨下动脉起源升主动脉远端或水平型主动脉弓后方。,约,7%9%,病人不适宜桡动脉操作，强行操作会增加桡动脉特有并发症的发生。,独有并发症,桡动脉痉挛,：平滑肌受,肾上腺受体控制，易痉挛。与紧张、反复穿刺、麻醉不充分、粗暴送入钢丝和导管有关,术前充分镇静、提高穿刺成功率、使用硝酸甘油或维拉帕米有效。,严重痉挛导致,鞘管或导管无法拔出,避免强行，应该在病人充分放松后延迟拔。,血肿,：桡动脉破裂血肿导致前臂挤压综合征，发生率低，但未及时减压处理，可终身致残。,前臂筋膜综合征,在肢体骨和筋膜形成的间隔区内，各种原因造成组织压上升，致血管受压，血液循环障碍，肌肉、神经组织严重供血不足，发生缺血坏死，最终导致,些组织功能损害，由此而产生的一系列症候群，统称为,筋膜间隔区综合征,。,通常缺血,30,分钟，即发生神经功能异常；完全缺血,12,24,小时后，则发生肢体永久功能障碍，出现肌肉挛缩、感觉异常、运动丧失等表现。典型者,五“,P”,症,：由疼痛转为无痛（,Painless,）,;,苍白（,Pallor,）或紫绀，大理石花纹等,;,感觉异常（,Paresthesia,）；肌肉瘫痪（,Paralysis,），无脉（,Pulselessness,）。,预防方法：避免反复多次透壁穿刺，尽量小鞘管，导引钢丝永远至于导管的前方，轻柔操作。,前臂水肿,长时间过度压迫导致静脉回流不畅，,尤其在合并前臂血肿时更易出现。,一般,2,小时,应该明显松解压迫，避免大面积的压迫桡动脉周围。,拔鞘,拔鞘后局部压一小沙布球，弹力绷带包扎：松紧适度，手腕制动,6,小时。观察末梢血供情况（颜色、温度）及患者感受，可每,2,小时松解一次。,Loop formation at the radial artery in a 75-year-old man interfered with insertion of the guide wire of the introducer sheath,During guide wire insertion through the radial artery, it entered the radial recurrent artery,返动脉, causing sharp pain in the forearm.,Thrombus migrating into the ulnar artery during DSA of the forearm artery performed at the end of the examination.,Ultrasonic assessment of vascular complications incoronary angiography and angioplasty after transradial approach.Am J Cardiol 1999;83:180 186.,Nagai et al. and Yokoyama et al.have reported three factors related to radial artery occlusion:,the diameter of the radial artery prior to the procedure,；,the ratio of the radial artery diameter to the sheath outer diameter,；,diabetes.,Limitations of Successive Transradial Approach in the Same Arm:,The Japanese Experience,Catheterization and Cardiovascular Interventions 54:204208 (2001),812 patients,TRA was successfully performed,three times,in 90% of the men and 80% of the women.,In conclusion, TRA in the same arm can be performed,three to five times,in most Japanese patients.,全脑血管造影,主动脉弓造影,猪尾导管,置于,升主动脉,内,Simmons,导管使用法,Simmons,导管有三型，即,I,、,、,型,(,图,),。,有较长的、开袢状的,两个弧与两个臂,。,I,型的远侧臂长,3.6cm,，,型远侧臂为,6.4cm,，,型为,8.4cm,。,根据,主动脉弓的直径,决定,导管远侧臂的长度应至少比要插管的血管水平处主动脉的宽度稍长，当注射造影剂时导管才不会弹出血管。,主动脉弓成袢方法：,2,种,成袢方法,2,种：,降主动脉成袢：较安全,升主动脉成袢：用于迂曲、扩张的主动脉弓，导丝不能到达降主动脉时,A method of folding the Simmons catheter curve using the aortic arch by the looping method (Method 1). (a) The tip of the catheter is negotiated into the,descending thoracic aorta,with the aid of the distal curve of the catheter and a J-tipped guide wire. (b) The main loop is formed by,pushing,the catheter into the ascending aortic arch while the guide wire is within the catheter with the tip,at the primary curve,of the catheter. (c) Now the curve is formed within the ascending aorta ready to select the supra-aortic branches.,A method within the,ascending aorta,(Method 2). With very tortuous and wide aortic arch, Method 1 cannot be utilized because,advancing the guide wire to the descending thoracic aorta is impossible.,(a) A guide wire loop is made within the ascending aorta with the top of the loop abutting the cusps of the aortic valve. (b) A catheter is then,advanced over the loop of the guide wire,. The course of the catheter and wire is blurred due to the cardiac motion. (c) Finally the catheter curve is obtained.,(a),L-SUB-VA,(b),L-CCA,(c),L-ICA,( with,acute branching pattern,use of a stiff guide ) (d),R-CCA,(e),R-SUB-VA,A. A,0.035-inch guide wire,was passed though the radial and brachial arteries. B. A guide wire and a,5-F Simon II catheter,were introduced into the,ascending aorta,. C. The guide wire was turned back at the aortic valve. D,. A J-curve,was made at the distal portion of the Simon II catheter,When handling the catheter, the brain supplying arteries can be easily selected.,A. L-CCAB. L-ICAC. R-CCAD. L-VA,A. During catheter handling to select the R-CCA, the,catheter kinked,because of excessive torque.,The innominate artery was very tortuous in this patient.,B. The catheter was withdrawn. Focal kinking is demonstrated in the catheter.,SimmonsIII,导管造影,注意,操作导管在,透视下,进行：进管、超选血管及撤管时；,导丝辅助,Simmons,导管独特的头端弯曲，应注意,避免损伤血管壁,一般应用导丝引导进入血管；,难点：,L-ICA,L-VA,（角度）,；,经验：一般应用,5F Simmons,导管,较易操作，不易纽结，尤其是血管迂曲者；,导管到达降主动脉困难,应用,猪尾导管长交换导丝,至降主动脉，再将,Simmons,导管交换到位，可用,方法,1,成袢。,少数可直接进入右侧颈总动脉内成袢,Transradial Approach for Diagnostic Selective Cerebral Angiography: Results of a Consecutive Series of 166 Cases.,AJNR Am J Neuroradiol,22:704708, April 2001,The radial artery was successfully punctured and cannulated in,154/ 166,patients.,Selective catheterization of the intended vessels was obtained in all carotid and vertebral angiographic procedures with,no major vascular complications,.,CONCLUSION:,Compared with transfemoral and transbrachial approaches,the transradial approach is a less invasive and safer technique for selective cerebral angiography,and may warrant consideration as a standard procedure.,Anticoagulant or antiplatelet therapy need not be discontinued for this method.,Transradial Cerebral Angiography: Technique and Outcomes,AJNR Am J Neuroradiol,24:12471250, June/July 2003,Successful cases,：,57 of 60 cases,.,Sheaths,：,4F to 6F,.,Mean procedural time for diagnostic cases was,40 minutes,19,SD.,Access-site,complications:,one forearm hematoma.,Routine transradial access for conventional cerebral angiography: a single operators experience of its feasibility and safety ,British Journal of Radiology (2004) 77, 831-838,The arterial access was successful in,96.3% .,The supra-aortic vessels were catheterized with success rates of,99.2%,(127/128),The mean,procedure time,was 19.3min (range 1055min).,The most frequent,complication,was arm pain which occurred in 37 patients (28.9%).,CONCLUSION:,Transradial angiography is a useful tool for diagnostic and interventional neuroangiographic procedures.,经桡动脉介入治疗,病例少,国内,：,经桡动脉行颈动脉狭窄支架成形术的疗效分析,2005,，,12,，,18,中国脑血管病杂志,国外,：,Neuroendovascular interventions for intracranial posterior circulation disease via the transradial approach: technical case report.,Neurosurgery. 2005 Mar;56(3,):,Carotid stent-supported angioplasty via,radiobrachial route,.,J Neuroimaging. 2006 Jul; 16(3) :,212-5.,Access site complications with carotid,angioplasty and stenting.,Surg Neurol. 2007,Oct;68(4):431-7.,Carotid artery stenting via transbrachial,approach,Rofo. 2008 Nov;180(11):988-93. Epub,2008 Oct 14.,经桡动脉行颈动脉狭窄支架成形术的疗效分析,2005,，,12,，,18,中国脑血管病杂志,Vascular intervention,Local cerebral thrombolysis.,The patient can be anticoagulated immediately after the procedure.,Vertebral artery angioplasty or stenting.,Patients with significant,tortuosity or ectatic,（迂曲扩张）,changes of the aortic arch,and in patients with,acute right VA,course from the SCA.,主动脉弓变异,