颈动脉支架手术步

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,颈动脉支架手术步骤,June 2005,Boston Scientific,循序渐进 建立标准,股动脉穿刺,7F or 8F,的套管针,7F,用于,8mm,以下的,Carotid Wallstent Monorail,8F,用于,10 mm,以下的,Carotid Wallstent,Monorail,1.,建立动脉通道,2.,血管造影确定病变,选择性颈总动脉造影,.035”,标准导丝,4F or 5F,造影导管,Imager II Headhunter or Sidewinder,3.,指引导管定位,置,stiff.035”,导丝于颈外动脉,通过,Y,接头，置指引导管于颈动脉分叉处下,1-2 cm,移出,.035”,导丝,4.,FilterWire EZ,动脉远端保护装置,回撤鞘和输送鞘（附有滤网的导丝）分别置于不同的保护盘内,黑色尾端：附有滤网的导丝和输送鞘,白色尾端,:,回撤鞘,撤除输送鞘，远端滤网显露出来,4-1,FilterWire EZ,动脉远端保护装置,准 备,用肝素盐水在原位冲洗输送鞘,取出附有滤网的导丝及输送鞘,滤网头端浸泡于肝素盐水中，移动输送鞘向上覆盖滤网，排除空气,导丝头端通过剥离鞘，置滤网导丝于,Y,阀中,4-1,FilterWire EZ,动脉远端保护装置,准 备,4-2,FilterWire EZ,动脉远端保护装置,理想的位置选择,滤网环,最顶点距离病变远端至少,3 cm,4-2,FilterWire EZ,动脉远端保护装置,理想的位置选择,3 cm minimum,1.5 cm minimum,血管直径介于,之间,5.5mm,3.5mm,4-2,FilterWire EZ,动脉远端保护装置,理想的位置选择,滤网放置于至少有,2cm,长的直血管,镍钛环距血管转弯处距离应,1cm,4-2,FilterWire EZ,动脉远端保护装置,理想的位置选择,4-3,FilterWire EZ,动脉远端保护装置,进 入,&,前 进,one hand and two hands tech,buddy wire?/,4-3,FilterWire EZ,动脉远端保护装置,进 入,&,前 进,4-4,FilterWire EZ,动脉远端保护装置,定 位,&,释 放,视角,1,:Appears apposed,视角,2,:confirm apposition with crescent shape,视角,2:Not apposed,4-4,FilterWire EZ,动脉远端保护装置,定 位,&,释 放,旋紧扭控器，固定导丝,/,滤网,滤网定位，从两个不同的角度（垂直）造影以确定镍钛环是否紧贴血管壁,通过剥离的方式，抽出输送鞘，释放滤网,A:,导丝的头端,B:,滤网远端标记,C:,输送鞘标记,D:,镍钛环,E:,滤网近端标记,Pre deployment,Post deployment,A,B,C,D,E,A,B,C,D,E,4-4,FilterWire EZ,动脉远端保护装置,定 位,&,释 放,4 5,FilterWire EZ,动脉远端保护装置,稳 定,&,血 流,随时稳定导丝,交换器械时,交换指引导管时,4 5,FilterWire EZ,动脉远端保护装置,稳 定,&,血 流,定期检查血流,如果血流较缓，须重新定位和释放,如果血流停止，立即撤出,，,Check Flow,4 5,FilterWire EZ,动脉远端保护装置,稳 定,&,血 流,1.PLACEMENT,:,确定滤网完全贴壁,2.POSITION:,手术的全过程中,保持滤网的位置不变,3.FLOW:,定期检查血流,4 5,FilterWire EZ,动脉远端保护装置,稳 定,&,血 流,4,FilterWire EZ,动脉远端保护装置,定 位,&,释 放,在病变远端植入好,FW EZ,远端保护装置后，,沿,FW EZ,的导丝将球囊推送到病变处,注意不要移动滤网,5.,球囊预扩张,球囊预扩张是为增加,支架的通过性作准备,6.,颈动脉支架术,Carotid Wallstent Monorail Placement,支架的准备：,阅读指南,确保无菌,确定支架密封在鞘管内,冲洗装置：,肝素盐水,5ml,冲洗支架内腔，见盐水从导丝口流出,堵住导丝口，继续冲洗，可见盐水从导管头端（鞘管头端标记处）流出，,Insertion,Load the stent catheter onto the proximal end of the FilterWire EX guidewire and advance the Carotid Wallstent to the lesion,沿着保护伞导丝送支架到病变处,Maintain the delivery instrument as straight as possible outside the body,保持体外输送系统尽量直,Advance the stent so that the radiopaque markers are positioned either side of the lesion to be stented,确定支架两端的标记在病变外端,If it is necessary to place a second Carotid Wallstent,allow a minimum overlap of 5mm,如果有用第二个支架，重叠部分最少要有,5mm,6.,颈动脉支架术,Carotid Wallstent Deployment Technique Review,As the Wallstent deploys,it shortens from both ends towards the middle,支架释放后，长度从两端向中间缩短,Place the proximal and distal X-ray markers in the inner shaft overlapping both sides of the stenosis,内杆上支架两端的标记要超过狭窄的范围,Deploy the Carotid Wallstent,slowly,a few millimeters at a time,释放支架需要较慢的速度,Up to about half way it is possible to recapture the stent and re-position it,支架释放一半以上时，还可以重新回收，重新定位,6.,颈动脉支架术,Carotid WallstentDeployment,Immobilize the stainless steel tube,固定不锈钢管,Slide the T-connector gently towards the black release marker until the Carotid Wallstent is,50%deployed,.,在支架释放小于,50%,时，将,T,连接向黑色释放标记移动，,Check position of the partially deployed Carotid Wallstent within the stenosis,检查狭窄病变内部分释放的支架,Contrast medium can be injected through the guiding catheter,造影剂可以通过指引导管注入,CAUTION:Do not push the stainless steel tube!,注意：千万不要推动不锈钢管,6.,颈动脉支架术,Carotid WallstentDeployment,Immobilize the stainless steel tube again,When the Carotid Wallstent is in its final position,gently slide the T-connector on the stainless steel tube towards the heart shaped hub until the stent is completely deployed.,Carefully remove the stent catheter,under fluoroscopic guidance,leaving the guidewire in place,支架定位后，固定不锈钢管，向前推动,T,管，完全释放支架,CAUTION:,If the tip of the Carotid Wallstent nose cone catches the distal ends,free it with gentle movements!,如果支架的头端触及滤网的远端，轻柔将其移开,6.,颈动脉支架术,6.,颈动脉支架术,7.,球囊后扩张,后扩的目的：,Ensure good in-flow and out-flow characteristic,确保流速正常,Good stent to wall apposition,支架贴壁更好,CAUTION:,Closely monitor the ECG trace in the event of bradycardia during the post dilatation step.,注意：如果后扩时出现心动过缓，密切注意心电图轨迹,.,Control Angiogram,？,Perform a control angiogram to confirm result of stent placement,4-6,FilterWire EZ,动脉远端保护装置,回 撤,4-6,FilterWire EZ,动脉远端保护装置,回 撤,沿着滤网导丝，用回撤鞘将滤网完全地回收至鞘内,（可见到镍钛环已进入到鞘远端的标记中）,将整个的回撤鞘连同滤网导丝作为一个整体同时撤出,4-6,FilterWire EZ,动脉远端保护装置,回 撤,4.,FilterWire EZ,动脉远端保护装置,Filterwire EZ,“EASY”,Final Results,The Guide Catheter can now be withdrawn and the procedure completed in the normal way,T,hank You,for your,Attention,!,