頸動(dòng)脈支架手術(shù)步

1、頸動(dòng)脈支架手術(shù)步驟June 2005,Boston Scientific,循序漸進(jìn) 建立標(biāo)準(zhǔn),,股動(dòng)脈穿刺7F or 8F 的套管針7F 用于 8mm 以下的 Carotid Wallstent? Monorail? 8F 用于10 mm 以下的 Carotid Wallstent? Monorail?,1.建立動(dòng)脈通道,2. 血管造影確定病變,選擇性頸總動(dòng)脈造影.035” 標(biāo)準(zhǔn)導(dǎo)絲4F or 5F 造影

2、導(dǎo)管Imager II Headhunter or Sidewinder,3. 指引導(dǎo)管定位,置 stiff .035” 導(dǎo)絲于頸外動(dòng)脈 通過(guò)Y接頭，置指引導(dǎo)管于頸動(dòng)脈分叉處下1-2 cm 移出 .035” 導(dǎo)絲,4. FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置,回撤鞘和輸送鞘（附有濾網(wǎng)的導(dǎo)絲）分別置于不同的保護(hù)盤(pán)內(nèi)黑色尾端：附有濾網(wǎng)的導(dǎo)絲和輸送鞘白色尾端: 回撤鞘,撤除輸送鞘，遠(yuǎn)端濾網(wǎng)顯露出來(lái),,

3、,,4-1 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 準(zhǔn) 備,用肝素鹽水在原位沖洗輸送鞘 取出附有濾網(wǎng)的導(dǎo)絲及輸送鞘 濾網(wǎng)頭端浸泡于肝素鹽水中，移動(dòng)輸送鞘向上覆蓋濾網(wǎng)，排除空氣 導(dǎo)絲頭端通過(guò)剝離鞘，置濾網(wǎng)導(dǎo)絲于Y閥中,4 - 1 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 準(zhǔn) 備,4 - 2 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 理想的

4、位置選擇,濾網(wǎng)環(huán)最頂點(diǎn)距離病變遠(yuǎn)端至少3 cm,4 - 2 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 理想的位置選擇,,,,3 cm minimum,1.5 cm minimum,血管直徑介于3.5 – 5.5mm之間,,,,,,4 - 2 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 理想的位置選擇,濾網(wǎng)放置于至少有2cm長(zhǎng)的直血管 鎳鈦環(huán)距血管轉(zhuǎn)彎處距離應(yīng) > 1cm

5、,4 - 2 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 理想的位置選擇,4 - 3 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 進(jìn) 入 & 前 進(jìn),one hand and two hands tech buddy wire ?/,4 - 3 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 進(jìn) 入 & 前 進(jìn),4 - 4 FilterWire

6、 EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 定 位 & 釋 放,視角 1: Appears apposed,視角 2: confirm apposition with crescent shape,視角 2: Not apposed,4 - 4 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 定 位 & 釋 放,旋緊扭控器，固定導(dǎo)絲/濾網(wǎng) 濾網(wǎng)定位，從兩個(gè)不同的角度（垂直）造影以確定鎳鈦

7、環(huán)是否緊貼血管壁 通過(guò)剝離的方式，抽出輸送鞘，釋放濾網(wǎng),A: 導(dǎo)絲的頭端B: 濾網(wǎng)遠(yuǎn)端標(biāo)記C: 輸送鞘標(biāo)記D: 鎳鈦環(huán)E: 濾網(wǎng)近端標(biāo)記,Pre deployment,Post deployment,A,B,C,D,E,A,B,C,D,E,4 - 4 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 定 位 & 釋 放,4 – 5 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置

8、穩(wěn) 定 & 血 流,隨時(shí)穩(wěn)定導(dǎo)絲 交換器械時(shí) 交換指引導(dǎo)管時(shí),4 – 5 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 穩(wěn) 定 & 血 流,定期檢查血流 如果血流較緩，須重新定位和釋放 如果血流停止，立即撤出，,,Check Flow,4 – 5 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 穩(wěn) 定 & 血 流,1. PLACEMENT: 確定濾網(wǎng)完全貼

9、壁2. POSITION:手術(shù)的全過(guò)程中,保持濾網(wǎng)的位置不變3. FLOW:定期檢查血流,4 – 5 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 穩(wěn) 定 & 血 流,4 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 定 位 & 釋 放,在病變遠(yuǎn)端植入好FW EZ?遠(yuǎn)端保護(hù)裝置后， 沿FW EZ?的導(dǎo)絲將球囊推送到病變處 注意不要移動(dòng)濾網(wǎng),5. 球

10、囊預(yù)擴(kuò)張,球囊預(yù)擴(kuò)張是為增加支架的通過(guò)性作準(zhǔn)備,6. 頸動(dòng)脈支架術(shù),Carotid Wallstent? Monorail? Placement 支架的準(zhǔn)備：閱讀指南確保無(wú)菌確定支架密封在鞘管內(nèi) 沖洗裝置： 肝素鹽水5ml沖洗支架內(nèi)腔，見(jiàn)鹽水從導(dǎo)絲口流出 堵住導(dǎo)絲口，繼續(xù)沖洗，可見(jiàn)鹽水從導(dǎo)管頭端（鞘管頭端標(biāo)記處）流出，,InsertionLoad the stent cathete

11、r onto the proximal end of the FilterWire EX? guidewire and advance the Carotid Wallstent? to the lesion沿著保護(hù)傘導(dǎo)絲送支架到病變處Maintain the delivery instrument as straight as possible outside the body保持體外輸送系統(tǒng)盡量直Advance the st

12、ent so that the radiopaque markers are positioned either side of the lesion to be stented確定支架兩端的標(biāo)記在病變外端If it is necessary to place a second Carotid Wallstent allow a minimum overlap of 5mm如果有用第二個(gè)支架，重疊部分最少要有5mm,6. 頸動(dòng)

13、脈支架術(shù),Carotid Wallstent? Deployment Technique ReviewAs the Wallstent deploys, it shortens from both ends towards the middle 支架釋放后，長(zhǎng)度從兩端向中間縮短 Place the proximal and distal X-ray markers in the inner shaft overlapping bo

14、th sides of the stenosis內(nèi)桿上支架兩端的標(biāo)記要超過(guò)狹窄的范圍Deploy the Carotid Wallstent slowly a few millimeters at a time釋放支架需要較慢的速度Up to about half way it is possible to recapture the stent and re-position it支架釋放一半以上時(shí)，還可以重新回收，重新定位

15、,6. 頸動(dòng)脈支架術(shù),Carotid Wallstent?DeploymentImmobilize the stainless steel tube 固定不銹鋼管Slide the T-connector gently towards the black release marker until the Carotid Wallstent is 50% deployed. 在支架釋放小于50%時(shí)，將T連接向黑色釋放標(biāo)記移動(dòng)，C

16、heck position of the partially deployed Carotid Wallstent within the stenosis 檢查狹窄病變內(nèi)部分釋放的支架Contrast medium can be injected through the guiding catheter造影劑可以通過(guò)指引導(dǎo)管注入CAUTION: Do not push the stainless steel tube!注意：千

17、萬(wàn)不要推動(dòng)不銹鋼管,6. 頸動(dòng)脈支架術(shù),Carotid Wallstent?DeploymentImmobilize the stainless steel tube againWhen the Carotid Wallstent is in its final position, gently slide the T-connector on the stainless steel tube towards the heart s

18、haped 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，固定不銹鋼管，向前推動(dòng)T管，完全釋放支架CAUTION: If the tip of the Carotid Wallstent n

19、ose cone catches the distal ends, free it with gentle movements!如果支架的頭端觸及濾網(wǎng)的遠(yuǎn)端，輕柔將其移開(kāi),6. 頸動(dòng)脈支架術(shù),6. 頸動(dòng)脈支架術(shù),7. 球囊后擴(kuò)張,后擴(kuò)的目的：Ensure good in-flow and out-flow characteristic確保流速正常Good stent to wall apposition支架貼壁更好CA

20、UTION: Closely monitor the ECG trace in the event of bradycardia during the post dilatation step.注意：如果后擴(kuò)時(shí)出現(xiàn)心動(dòng)過(guò)緩，密切注意心電圖軌跡,,. Control Angiogram？？Perform a control angiogram to confirm result of stent placement,4 - 6

21、 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 回 撤,,4 - 6 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 回 撤,沿著濾網(wǎng)導(dǎo)絲，用回撤鞘將濾網(wǎng)完全地回收至鞘內(nèi) （可見(jiàn)到鎳鈦環(huán)已進(jìn)入到鞘遠(yuǎn)端的標(biāo)記中） 將整個(gè)的回撤鞘連同濾網(wǎng)導(dǎo)絲作為一個(gè)整體同時(shí)撤出,4 - 6 FilterWire EZ?動(dòng)脈遠(yuǎn)端保護(hù)裝置 回 撤,4 . FilterWire EZ?動(dòng)脈遠(yuǎn)端