指引導(dǎo)管的選擇和操作技術(shù)課件

LiYue,M.D.TheFirstAffiliatedHospitalofHarbinMedicalUniversity指引導(dǎo)管的選擇和操作技術(shù)LiYue,M.D.TheFirstAffiliat1

3000B.C.—Egyptiansperformbladdercatheterizationsusingmetalpipes.

400B.C.—Cathetersfashionedfromhollowreedsandpipesareusedincadaverstostudythefunctionofcardiacvalves.人類使用導(dǎo)管的歷史3000B.C.—Egyptiansperform2

1711—Halesconductsthefirstcardiaccatheterizationofahorseusingbrasspipes,aglasstubeandthetracheaofagoose.1711—Halesconductsthefir31929年，德國外科醫(yī)生WernerForssmann將一根導(dǎo)尿管插入自己心臟，這是插入人體心臟的第一根導(dǎo)管。NobelPrize，1956Forhispioneeringefforts.1929年，德國外科醫(yī)生WernerForssmann將41958—Thediagnosticcoronaryangiogram–thekeytoselectiveimagingoftheheartisdiscoveredbyMasonSones.

1964—TransluminalAngioplasty,theconceptofremodelingtheartery,isintroducedbyCharlesT.Dotter.1958—Thediagnosticcoronar51967年，MelvinP.Judkins設(shè)計冠脈造影專用導(dǎo)管1967年，MelvinP.Judkins設(shè)計冠脈造影專61977—Gruentzig,performsfirstcathlabPTCA

onawakepatientinZurich;startingwiththiscase,allPTCAdataisenteredintoaworldwideregistry1977—Gruentzig,performsfi7輸送各種介入器械支持作用注射造影劑及各種相關(guān)治療、搶救藥物血流動力學(xué)監(jiān)測導(dǎo)引導(dǎo)管功能輸送各種介入器械導(dǎo)引導(dǎo)管功能8導(dǎo)引導(dǎo)管選擇要求創(chuàng)傷小同軸性好支撐力好足夠管腔直徑導(dǎo)引導(dǎo)管選擇要求創(chuàng)傷小9柔軟的可視頭端（安全區(qū)）柔軟的同軸段（柔軟區(qū)或傳送區(qū)）中等硬度的抗折段（支撐區(qū)）牢固的扭控段（扭控區(qū)或推送區(qū)）導(dǎo)引導(dǎo)管節(jié)段柔軟的可視頭端（安全區(qū)）導(dǎo)引導(dǎo)管節(jié)段10導(dǎo)引導(dǎo)管構(gòu)造外層—聚乙烯塑料決定導(dǎo)管形狀、硬度和與血管內(nèi)膜間的摩擦力中層—12-16根鋼絲編織成，使導(dǎo)管具備抗折斷、抗扭曲、順應(yīng)性和彈性（不同廠家編織方式不同）內(nèi)層—尼龍聚四氟乙烯（PTFE）涂層，減少導(dǎo)絲、球囊、支架與導(dǎo)管內(nèi)腔間摩擦力，抗血栓導(dǎo)引導(dǎo)管構(gòu)造11支撐力內(nèi)徑大小順應(yīng)性扭控性抗折性導(dǎo)引導(dǎo)管性能參數(shù)鈣化迂曲閉塞支撐力導(dǎo)引導(dǎo)管性能參數(shù)鈣化迂曲閉塞12導(dǎo)引導(dǎo)管支撐力

被動支撐（通過導(dǎo)管結(jié)構(gòu)和外形獲得支持）

主動支撐（術(shù)者操作獲得）導(dǎo)引導(dǎo)管支撐力被動支撐（通過導(dǎo)管結(jié)構(gòu)和外形獲得支持）13被動支撐力取決于直徑、結(jié)構(gòu)、導(dǎo)管與主動脈壁接觸面積和夾角。1、直徑越大、支持力越強。被動支撐力取決于直徑、結(jié)構(gòu)、導(dǎo)管與主動脈壁接觸面積和夾角。142、中層鋼絲編織方式。一圓一扁鋼絲編織成的相對較硬、支持力強；扁平鋼絲編織成的導(dǎo)管柔軟、支持力弱。

CordisVistaMedtronicLauncher2、中層鋼絲編織方式。CordisVistaMedtron15BostonMach12X2編織:2根圓鋼絲在另2根圓鋼絲之上BostonRunway4X2編織:抗折性、扭控性更好BostonMach12X2編織:BostonR163、導(dǎo)管與主動脈內(nèi)壁接觸面積越大，支持力越強。JL4.0SL4.0EBU3.753、導(dǎo)管與主動脈內(nèi)壁接觸面積越大，支持力越強。JL4.0S174、導(dǎo)管與主動脈夾角越接近90度，支持力越強，夾角越小，越差。4、導(dǎo)管與主動脈夾角18主動支撐力Deepseating使其與主動脈夾角更趨于90度JL4.0主動支撐力Deepseating使其與主動脈夾角更趨于9019Downsizingfrom(6F)to(5F)afterrotationalatherectomyviatranradialapproachwithsafedeepcannulationmaybeasolutiontocompasslacksofsupportandtoleadtocrossthecalcifiedlesionsanddeploymentofthestent.DeepseatingCardiovascularResvacularizationMedicine,2011Downsizingfrom(6F)to(5F)a201.5mmbur6FEBU1.5mmbur6FEBU21Deepseating5FEBUDeepseating5FEBU22深插方法（避免開口部損傷）深插方法（避免開口部損傷）23內(nèi)徑大小內(nèi)徑大小24MedtronicLauncher大腔導(dǎo)管TerumoFullWall技術(shù)Medtronic大腔導(dǎo)管TerumoFullWall技術(shù)25指導(dǎo)管在體內(nèi)被旋轉(zhuǎn)、操控的能力。決定于鋼絲編織方式和polymer特性。扭控力、抗折力指導(dǎo)管在體內(nèi)被旋轉(zhuǎn)、操控的能力。扭控力、抗折力26導(dǎo)引導(dǎo)管類型導(dǎo)引導(dǎo)管類型27Judkins導(dǎo)管（操作簡單，適用于簡單、中等難度病變）常用導(dǎo)引導(dǎo)管點狀被動支撐不與動脈壁接觸源于導(dǎo)管本身結(jié)構(gòu)Judkins導(dǎo)管（操作簡單，適用于簡單、中等難度病變）常用28Judkins導(dǎo)管型號Judkins導(dǎo)管型號29短頭導(dǎo)管正常短頭導(dǎo)管正常30短頭導(dǎo)管正常短頭導(dǎo)管正常31XB3.5支撐力較JL增加67%CordisVistaBriteTipExtraBackup類導(dǎo)引導(dǎo)管JL基礎(chǔ)上改進(jìn)頭端直線形，更好同軸第二彎曲與左冠開口對側(cè)主動脈壁貼合更長選擇XB應(yīng)比JL小0.5XB3.5支撐力較JL增加67%CordisVista32XBLADXBC支撐力較JL增加50%形狀介于XB和XBLAD之間操作方便XBLADXBC支撐力較JL增加50%形狀介于XB33弧度較大的第二彎曲緊靠對側(cè)主動脈壁。MedtronicEBU弧度較大的第二彎曲緊靠MedtronicEBU34BostonleftspecialtycurvesLAD通常選Qcurve4通常選Voda3.5支撐力更好BostonleftspecialtycurvesLA35XBRCAARTMAC(MultiAorticCurve)對側(cè)壁提供后座力支持力介于JR和Amplatz之間與BSC的ART或MDT的MAC相似XBRCAARTMAC(MultiAorticCurv36頭端直線形，通過對側(cè)壁提供額外后座力同時可深插適合開口向下RCA與BSC的VodaRight或MDT的ECR相似。XBRECR頭端直線形，通過對側(cè)壁提供額外后座力同時可深插XBRECR37指引導(dǎo)管的選擇和操作技術(shù)課件38MedtronicRBU（Rightbackup)對側(cè)壁支撐適合開口平行或向下RCA通常插入10-12mm介于MAC和Amplatz之間通常使用RBU3.5MACMedtronicRBU（Rightbackup)對39Amplatz導(dǎo)管

良好的同軸和被動支持力，可用于多數(shù)起源異常冠狀動脈。根據(jù)L段長短分為AL0.75、AL1、AL1.5、AL2、AL3、AL4根據(jù)R段的長短分為AR1、AR2Amplatz導(dǎo)管40指引導(dǎo)管的選擇和操作技術(shù)課件41第二彎曲與冠狀竇及對側(cè)壁貼合，多點支撐AL2用于LCAAL1、0.75用于RCAAL第二彎曲與冠狀竇及AL42AR第二彎曲小限制器械通過支撐力弱僅用于“牧羊鉤”樣RCAAR第二彎曲小43進(jìn)出導(dǎo)管時需注意：1、當(dāng)Amplatz導(dǎo)管的“L”或“R”段位于冠狀動脈開口水平線上方時，可直接撤出或深插導(dǎo)管。進(jìn)出導(dǎo)管時需注意：442、當(dāng)“L”或“R”段位于冠狀動脈開口水平線下方時，切忌直接后撤導(dǎo)管，應(yīng)推送導(dǎo)管，以底部為支撐點，使導(dǎo)管尖端后退，離開冠脈開口，再旋轉(zhuǎn)導(dǎo)管。推送旋轉(zhuǎn)2、當(dāng)“L”或“R”段位于冠狀動脈開口水平線下方時，切忌直接45短頭Amplatz導(dǎo)管標(biāo)準(zhǔn)短頭刮傷主動脈竇情況大大降低，造成靶血管撕裂、夾層可能降到最低入冠不深，幾乎沒有嵌頓現(xiàn)象、短頭Amplatz導(dǎo)管標(biāo)準(zhǔn)短頭刮傷主動脈竇情況46其他導(dǎo)引導(dǎo)管主要適用于向下的冠脈開口，可用于LCA和RCA。MP其他導(dǎo)引導(dǎo)管主要適用于向下的冠脈開口，可用于LCA和47

向上開口RCA和橋血管支撐力介于JR和Amplatz之間第一個彎較直，便于輸送器械

HSII用于正常直徑主動脈,HSI用于窄主動脈HSIII用于寬主動脈向上開口RCA和橋血管48Medtronic主要用于開口向上血管Medtronic主要用于開口向上血管49導(dǎo)引導(dǎo)管選擇同軸導(dǎo)引導(dǎo)管選擇同軸50同軸不良引起冠脈開口損傷同軸不良引起冠脈開口損傷51指引導(dǎo)管的選擇和操作技術(shù)課件52型號選擇開口高，選小號開口低，選大號型號選擇開口高，選小號53LCA導(dǎo)引導(dǎo)管選擇JL4開口高或主動脈根部小，可用JL3.5LM短，用短頭扭曲、鈣化、閉塞用Amplatz或ExtrabackupLCA導(dǎo)引導(dǎo)管選擇JL454RCA導(dǎo)引導(dǎo)管選擇JR4開口向上，用Amplatz或HockeystickRCA導(dǎo)引導(dǎo)管選擇JR455JL3.5開口向上或水平JL3.5開口向上或水平56冠脈起源異常導(dǎo)管選擇左冠口起源于右冠竇，選JR4或Amplatz右冠起源于左冠竇，選Amplatz或JL

升主動脈造影或CTA有幫助LCA起源右冠竇冠脈起源異常導(dǎo)管選擇左冠口起源于右冠竇，選JR4或Ampl57三維導(dǎo)管在不同軸向上進(jìn)行各種彎曲、形狀的設(shè)計如3DRC(Mdetronic)導(dǎo)管。三維導(dǎo)管在不同軸向上進(jìn)行各種彎曲、形狀的設(shè)計如3DR58SherpaNXActive3DRCA螺旋狀尾端第2、3彎頂在主動脈壁提供強支撐0.032inch導(dǎo)絲引導(dǎo)進(jìn)入后順時針或逆時針旋轉(zhuǎn)SherpaNXActive3DRCA螺旋狀尾端59AP-Cranial見RCA起源于左竇AP-Cranial見RCA起源于左竇60LAO見RCA起源異常LAO見RCA起源異常61橋血管導(dǎo)引導(dǎo)管選擇靜脈橋血管導(dǎo)管選擇常憑經(jīng)驗

CTA或升主動脈造影有幫助橋血管導(dǎo)引導(dǎo)管選擇靜脈橋血管導(dǎo)管選擇常憑經(jīng)驗62LCB

(Leftcoronarybypass)/RCB(Rightcoronarybypass)導(dǎo)引導(dǎo)管LCB(Leftcoronarybypass)63右冠橋血管右冠橋血管多起源于主動脈根部上方2-3cm的前壁，開口多向下，選擇MP、Amplatz或RCB。右冠橋血管右冠橋血管多起源于主動脈根部上方2-64左冠橋血管前降支和回旋支橋血管開口起源于右冠橋上側(cè)方，選擇JR、LCB、HockeyStick、Amplatz或MP。左冠橋血管前降支和回旋支橋血管開口起源于右冠橋上65開口如無明顯成角，用JR4或LCB明顯成角者用專用導(dǎo)管（IMA)可選擇左側(cè)橈動脈入路LIMA橋血管IMA開口如無明顯成角，用JR4或LCBLIMA橋血管IMA66LCBIMAJRLCBIMAJR67需要更大支持力怎么辦？更大直徑深插（頭端較直、較細(xì)導(dǎo)管更易深插，且可減少對冠脈損傷）

子母導(dǎo)管需要更大支持力怎么辦？更大直徑68HeartrailII(Terumo,Japan)long(120cm)5Frcatheter(13cmverysoftendportion)

Absenceofcurveandtheflexibilityofitstippermitthe“child”cathetercoaxialwiththetargetvessel,minimizingtheriskofdissection.5in6guidingcathetertechniqueInnercatheterHeartrailII(Terumo,Japan)569Filledwithwaterthatwaskeptat37°C5mm/sFilledwithwaterthatwaskep70Switchingto5-in-6systemSwitchingto5-in-6system71CoronaryarteryinjuryDeep-vesselengagementcanbefacilitatedbypassageofaballooncatheter

AirembolismCoronaryarteryinjury727FAL-1;3.5mmballoon7FAL-1;3.5mmballoon73指引導(dǎo)管的選擇和操作技術(shù)課件74(Goodman,Japan)(Goodman,Japan)75ThelumensizeoftheaspirationcatheterasthesizeofSESislimitedto3.0mm.Thelumensizeoftheas76GuideLinercath

Rapidexchange

Flexibleyellow20cmstraightextensionconnectedtoastainless-steelpushtubeResultsinanI.D.approximately1Fsizesmalleravailableinthreesizes:6F,7Fand8FGuideLinercathRapidexchang77指引導(dǎo)管的選擇和操作技術(shù)課件78指引導(dǎo)管的選擇和操作技術(shù)課件79指引導(dǎo)管的選擇和操作技術(shù)課件80Notrecommenditsuseintargetvesselsof<2.5mmdiameterNotrecommenditsuseintarge81

Softertipandhydrophiliccoatingoninsideandoutside.5-FrST01hasthecoatingonlyontheinside.CatheterizationandCardiovascularInterventions76:919–923(2010)(Terumo,Japan)Softertipandhydrophilicco82KIWAMIST01KIWAMIST0183Backupsupport

ofGCCircCardiovascInterv.2011Apr1;4(2):155-61BackupsupportofGCCircCardi845-in-6systemExtending≥3cm,thebackupsupport>7FGC5-in-6system854-in-6systemExtending≥5cm,thebackupsupportsigni?cantlyincreasedbutstill<7FGC4-in-6system86TrackabilityofGCUsingballoon-anchoringtechnique5Fchildcathetercouldbeadvancedto13.0cm,whereasthe4Fchildcathetercouldbeadvancedto15.0cm(P<0.005).TrackabilityofGCUsingballo87Provided>90%successratefor51lesionsinwhichconventionaltechniqueshadfailed.Successmaybecontributed,inmostpart,bythe

trackabilityofthe4Fchildcatheter.Doesnotusuallycompromisethecoronaryflow.Provided>90%successratefor88Peripheralballoonanchormethod

Balloonusedforpredilatationtothemostdistalportionofthelesion.In?atedandusedastheanchorKIWAMIisinsertedslowlytowardin?atedanchoringballoon.

NottodilatetheballoonatthehealthyportionPeripheralballoonanchormeth89Cypher(3.0×18mm)Cypher(3.0×18mm)905-FrST01allowsanyBMSandDESKIWAMIeffectiveforstentswithadiameterupto3.0mmforCypherandTAXUSLiberte,3.5mmforEndeavor

MostofBMScanbedeployedusingKIWAMIexceptDRIVER(Medtronic)5-FrST01allowsanyBMSand91經(jīng)橈動脈PCI導(dǎo)引導(dǎo)管選擇和經(jīng)股動脈基本原則一致右側(cè)橈動脈導(dǎo)管型號比股動脈小半號，左側(cè)和股動脈相同經(jīng)橈動脈PCI導(dǎo)引導(dǎo)管選擇和經(jīng)股動脈基本原則一致92ComparingthebackupforcebetweenTFIandTRIitwasfoundtobe60%greaterinTFIwitha

JLcatheter,and8%greaterinTFIwithabackup(EBU/XB)typecatheter.

JInvasiveCardiol.2005Dec;17(12):636-41Comparingthebackupforcebet93theIkariL(IL)cathetergeneratedasimilarbackupforcebetweenTRIandTFI.特有的第1彎曲利用右鎖骨下動脈和無名動脈間夾角提供強支撐力JInvasiveCardiol.2005Dec;17(12):636-41經(jīng)橈動脈PCI專用導(dǎo)引導(dǎo)管theIkariL(IL)cathetergene94JLILJRIRJLILJRIR95Fajadet導(dǎo)管JFLJFR(France)Longtip設(shè)計提供良好支撐力和同軸性。Fajadet導(dǎo)管JFLJFR(France)Longti96MUTA-L/RMUTAL導(dǎo)管和JL導(dǎo)管相似，但支撐力比后者強，MUTAR導(dǎo)管彎曲是一種三維設(shè)計，有MR2和MR3兩種，MR2最常使用。MUTA-L/RMUTAL導(dǎo)管和JL導(dǎo)管相似，但97適合右側(cè)橈動脈入路，可用于左右冠和靜脈橋，較Judkins導(dǎo)管同軸性和主、被動支撐力好，易于操控，但較long-tip導(dǎo)管支撐力差。左右共用導(dǎo)引導(dǎo)管AMI病變,直接使用節(jié)省時間KIMNY?Curve適合右側(cè)橈動脈入路，可用于左右冠和靜脈橋，較Judki98RadialBrachial(Cordis)

3個彎度設(shè)計；適于水平或開口向下病變可以深插；左右橈動脈入路均可。RadialBrachial(Cordis)3個99RadialRunway適合右側(cè)橈動脈入路，可用于左右冠和靜脈橋，結(jié)構(gòu)特點類似與KIMNY。分為標(biāo)準(zhǔn)、短頭和高位開口頭。RadialRunway適合右側(cè)橈動脈入路，可用于左100Barbeau導(dǎo)管Barbeau導(dǎo)管101Male（mm）Female（mm）國外3.1±0.6

2.8±0.6

魏盟2.7±0.4

2.3±0.4

賈三慶2.65±0.60

2.20±0.49

RadialarterydiameterMale（mm）Female（mm）國外3.1±0.62.102radialarteryinternaldiameter/

sheathexternaldiameter4%inpatientswithratio>113%inpatientswithratio<1Thedosageofheparin,thediameterofradialarteryandthepost-procedurecompressionpressureandtimewere

independentriskfactorsforRAOCathetCardiovascDiagn1997;40:156–158

radialarteryinternaldiamete103Radialarterydiameter6Fsheathexternaldiameter=2.62mmRadialarterydiameter6Fsheat104MMainprox.firstAMainAccrosssidefirstDDistalfirstSSidebranchfirstExtendedVSkirtPMstentingMBstentingacrossSBMBstenting+kissingMBstenting+SBballoonElectiveTstentingInternalcrushCulotteTAPDMstentingProvisionalSKSVstentingSKSTrouserlegsandseatSBostialstentingSBminicrushSBcrushSyst.TStentingMinicrushCrushAfterballoon2stents3stents1ststentSkirt+DMSkirt+SBStrategyselection(6F)MADSclassificationY.Louvard,CCVIpendingMADSExtendedVSkirtPMMBstent105Guidingcatheterselection

LargeinnerdiameterLauncher(Medtronic)andHeartrailII(Terumo)

Goodback-upsupport

LCA:EBU,BL,XB,Voda,Q-curve,IkariLRCA:AL-0.75/1,AR-1/2,JR,JL3.5,XBRCAGuidingcatheterselection106Radialarterydiameter5Fsheathexternaldiameter=2.29mmRadialarterydiameter5Fsheat1070.010-inchguidewireandcompatibleballooncatheter,IKAZUCHI-X

(KANEKAMedixCorporationOsaka,Japan)Doubleballoonin?ationwitha5-FrguidingcatheterTripleballoonin?ationwitha6-Frguidingcatheter6F0.010-inchguidewireandcompa108ComparisonofprofileamongballooncathetersystemsComparisonofprofileamongba109Coil-typeguidewires:

AthleteSlender01(JapanLifeLine,Tokyo,Japan)DecillionFL,andDecillionMD

(Asahiintecc,Nagoya,Japan)Hydrocoatedguidewire：theAthleteEelSlender(JapanLifeLine,Tokyo,Japan)IKAZUCHI-X

Semi-compliantballoon

Diametersfrom1.5to3.5mmLengthis9mmfora1.5mmdiameterand15mmforotherdiametersNominalpressureis8atm,ratedburstpressureis14atm.Coil-typeguidewires:110RadialarterydiameterThefrequencyofthisratio(≥1.0)for7and8Frsheathswas71.5%and44.9%inmalepatientsand40.3%and24.0%infemalepatients.RadialarterydiameterThefreq1117Fsheathandguidingcatheter7Fsheathandguidingcatheter112指引導(dǎo)管的選擇和操作技術(shù)課件113指引導(dǎo)管的選擇和操作技術(shù)課件114SheathlessGCsystem(AsahiIntecc,Japan)hydrophilicGC+centraldilator.SheathlessGCsystem(AsahiI115Theouterdiameterofthe6.5FsheathlessGC(2.16mm)issmallerthana5Fsheath(2.29mm).Theouterdiameterofthe7.5Fsheathless

GC(2.49mm)islessthanthatofa6Fsheath(2.62mm).Thickerthanconventionalguidecathetersduetoanadditionlayerofsteelbraidingandthehydrophiliccoating,aidsbackupsupport.Theouterdiameterofthe6.5116Afterthediagnosticangiography,thesheathwasexchangedforthesheathlesscatheteroverastandard150cmJ-tipped0.035-inch(Terumo?,Japan)wire.Afterthediagnosticangiograp117指引導(dǎo)管的選擇和操作技術(shù)課件118SheathlessGCsslideeasilywithinvesselsduetothehydrophiliccoating,disengagementofthecathetercouldhappenincasesrequiringgoodguidingsupport.TegadermadhesivedressingSheathlessGCsslideeasilyw119DisadvantageTheshapesofcatheterswereslightlydiferentfromthoseofconventionalcatheters.Thissystemrequiresmoretimetoassemble

Extracareshouldbeexercisedwhencoronaryintubationisattemptedtopreventcathetertipinducedcoronaryarterydissection.Disadvantage120指引導(dǎo)管的選擇和操作技術(shù)課件121指引導(dǎo)管的選擇和操作技術(shù)課件122PerformedPCIin100consecutivecasesusing6.5FrsheathlessguidesRadialocclusionrateof2%using6.5Frcatheters,0%

with4Frsystemsand1–7%with5Frsystems,6–11%

with6Frguidecatheters.Radialspasmrateof5%using6.5Frcatheters,1.1%with5Frsystems,22%using6FrSheaths.UKPerformedPCIin100consecuti123Severearteryspasm:makingmanipulationdifficult

Upperlimbarteryspasm

Highoriginofradialartery

Accessorybrachialartery√Severearteryspasm:makingma124指引導(dǎo)管的選擇和操作技術(shù)課件125指引導(dǎo)管的選擇和操作技術(shù)課件126TheconventionalGCdidnotpassthroughbifurcationhighoriginradialartery.6.5FrsheathLessGCpassedthroughTheconventionalGCdidnotpa127“Pseudo-taper”Guidecathetersinsertedwithalong(125cm)5or6FrIn?nitiDiagnosticCatheter(CordisCorporation,Miami,FL)overa0.035inchJ-tipguidewireUSA“Pseudo-taper”USA128CatheterizationandCardiovascularInterventions76:911–916(2010)CatheterizationandCardiovasc129導(dǎo)引導(dǎo)管手工塑型“釣魚”技術(shù)先送入導(dǎo)絲甚至球囊或微導(dǎo)管，再送入導(dǎo)引導(dǎo)管導(dǎo)引導(dǎo)管手工塑型“釣魚”技術(shù)先送入導(dǎo)絲甚至球囊或微導(dǎo)管，再送130指引導(dǎo)管的選擇和操作技術(shù)課件1318FAL1guidingcatheter(arrow)5Fmultipurposeinnercatheter(arrowhead)‘‘coaxialdoublecatheter’’8FAL1guidingcatheter(arro132300cm-longBMWBuddywire300cm-longBMW133指引導(dǎo)管的選擇和操作技術(shù)課件134指引導(dǎo)管的選擇和操作技術(shù)課件135Thanks!Thanks!136LiYue,M.D.TheFirstAffiliatedHospitalofHarbinMedicalUniversity指引導(dǎo)管的選擇和操作技術(shù)LiYue,M.D.TheFirstAffiliat137

3000B.C.—Egyptiansperformbladdercatheterizationsusingmetalpipes.

400B.C.—Cathetersfashionedfromhollowreedsandpipesareusedincadaverstostudythefunctionofcardiacvalves.人類使用導(dǎo)管的歷史3000B.C.—Egyptiansperform138

1711—Halesconductsthefirstcardiaccatheterizationofahorseusingbrasspipes,aglasstubeandthetracheaofagoose.1711—Halesconductsthefir1391929年，德國外科醫(yī)生WernerForssmann將一根導(dǎo)尿管插入自己心臟，這是插入人體心臟的第一根導(dǎo)管。NobelPrize，1956Forhispioneeringefforts.1929年，德國外科醫(yī)生WernerForssmann將1401958—Thediagnosticcoronaryangiogram–thekeytoselectiveimagingoftheheartisdiscoveredbyMasonSones.

1964—TransluminalAngioplasty,theconceptofremodelingtheartery,isintroducedbyCharlesT.Dotter.1958—Thediagnosticcoronar1411967年，MelvinP.Judkins設(shè)計冠脈造影專用導(dǎo)管1967年，MelvinP.Judkins設(shè)計冠脈造影專1421977—Gruentzig,performsfirstcathlabPTCA

onawakepatientinZurich;startingwiththiscase,allPTCAdataisenteredintoaworldwideregistry1977—Gruentzig,performsfi143輸送各種介入器械支持作用注射造影劑及各種相關(guān)治療、搶救藥物血流動力學(xué)監(jiān)測導(dǎo)引導(dǎo)管功能輸送各種介入器械導(dǎo)引導(dǎo)管功能144導(dǎo)引導(dǎo)管選擇要求創(chuàng)傷小同軸性好支撐力好足夠管腔直徑導(dǎo)引導(dǎo)管選擇要求創(chuàng)傷小145柔軟的可視頭端（安全區(qū)）柔軟的同軸段（柔軟區(qū)或傳送區(qū)）中等硬度的抗折段（支撐區(qū)）牢固的扭控段（扭控區(qū)或推送區(qū)）導(dǎo)引導(dǎo)管節(jié)段柔軟的可視頭端（安全區(qū)）導(dǎo)引導(dǎo)管節(jié)段146導(dǎo)引導(dǎo)管構(gòu)造外層—聚乙烯塑料決定導(dǎo)管形狀、硬度和與血管內(nèi)膜間的摩擦力中層—12-16根鋼絲編織成，使導(dǎo)管具備抗折斷、抗扭曲、順應(yīng)性和彈性（不同廠家編織方式不同）內(nèi)層—尼龍聚四氟乙烯（PTFE）涂層，減少導(dǎo)絲、球囊、支架與導(dǎo)管內(nèi)腔間摩擦力，抗血栓導(dǎo)引導(dǎo)管構(gòu)造147支撐力內(nèi)徑大小順應(yīng)性扭控性抗折性導(dǎo)引導(dǎo)管性能參數(shù)鈣化迂曲閉塞支撐力導(dǎo)引導(dǎo)管性能參數(shù)鈣化迂曲閉塞148導(dǎo)引導(dǎo)管支撐力

被動支撐（通過導(dǎo)管結(jié)構(gòu)和外形獲得支持）

主動支撐（術(shù)者操作獲得）導(dǎo)引導(dǎo)管支撐力被動支撐（通過導(dǎo)管結(jié)構(gòu)和外形獲得支持）149被動支撐力取決于直徑、結(jié)構(gòu)、導(dǎo)管與主動脈壁接觸面積和夾角。1、直徑越大、支持力越強。被動支撐力取決于直徑、結(jié)構(gòu)、導(dǎo)管與主動脈壁接觸面積和夾角。1502、中層鋼絲編織方式。一圓一扁鋼絲編織成的相對較硬、支持力強；扁平鋼絲編織成的導(dǎo)管柔軟、支持力弱。

CordisVistaMedtronicLauncher2、中層鋼絲編織方式。CordisVistaMedtron151BostonMach12X2編織:2根圓鋼絲在另2根圓鋼絲之上BostonRunway4X2編織:抗折性、扭控性更好BostonMach12X2編織:BostonR1523、導(dǎo)管與主動脈內(nèi)壁接觸面積越大，支持力越強。JL4.0SL4.0EBU3.753、導(dǎo)管與主動脈內(nèi)壁接觸面積越大，支持力越強。JL4.0S1534、導(dǎo)管與主動脈夾角越接近90度，支持力越強，夾角越小，越差。4、導(dǎo)管與主動脈夾角154主動支撐力Deepseating使其與主動脈夾角更趨于90度JL4.0主動支撐力Deepseating使其與主動脈夾角更趨于90155Downsizingfrom(6F)to(5F)afterrotationalatherectomyviatranradialapproachwithsafedeepcannulationmaybeasolutiontocompasslacksofsupportandtoleadtocrossthecalcifiedlesionsanddeploymentofthestent.DeepseatingCardiovascularResvacularizationMedicine,2011Downsizingfrom(6F)to(5F)a1561.5mmbur6FEBU1.5mmbur6FEBU157Deepseating5FEBUDeepseating5FEBU158深插方法（避免開口部損傷）深插方法（避免開口部損傷）159內(nèi)徑大小內(nèi)徑大小160MedtronicLauncher大腔導(dǎo)管TerumoFullWall技術(shù)Medtronic大腔導(dǎo)管TerumoFullWall技術(shù)161指導(dǎo)管在體內(nèi)被旋轉(zhuǎn)、操控的能力。決定于鋼絲編織方式和polymer特性。扭控力、抗折力指導(dǎo)管在體內(nèi)被旋轉(zhuǎn)、操控的能力。扭控力、抗折力162導(dǎo)引導(dǎo)管類型導(dǎo)引導(dǎo)管類型163Judkins導(dǎo)管（操作簡單，適用于簡單、中等難度病變）常用導(dǎo)引導(dǎo)管點狀被動支撐不與動脈壁接觸源于導(dǎo)管本身結(jié)構(gòu)Judkins導(dǎo)管（操作簡單，適用于簡單、中等難度病變）常用164Judkins導(dǎo)管型號Judkins導(dǎo)管型號165短頭導(dǎo)管正常短頭導(dǎo)管正常166短頭導(dǎo)管正常短頭導(dǎo)管正常167XB3.5支撐力較JL增加67%CordisVistaBriteTipExtraBackup類導(dǎo)引導(dǎo)管JL基礎(chǔ)上改進(jìn)頭端直線形，更好同軸第二彎曲與左冠開口對側(cè)主動脈壁貼合更長選擇XB應(yīng)比JL小0.5XB3.5支撐力較JL增加67%CordisVista168XBLADXBC支撐力較JL增加50%形狀介于XB和XBLAD之間操作方便XBLADXBC支撐力較JL增加50%形狀介于XB169弧度較大的第二彎曲緊靠對側(cè)主動脈壁。MedtronicEBU弧度較大的第二彎曲緊靠MedtronicEBU170BostonleftspecialtycurvesLAD通常選Qcurve4通常選Voda3.5支撐力更好BostonleftspecialtycurvesLA171XBRCAARTMAC(MultiAorticCurve)對側(cè)壁提供后座力支持力介于JR和Amplatz之間與BSC的ART或MDT的MAC相似XBRCAARTMAC(MultiAorticCurv172頭端直線形，通過對側(cè)壁提供額外后座力同時可深插適合開口向下RCA與BSC的VodaRight或MDT的ECR相似。XBRECR頭端直線形，通過對側(cè)壁提供額外后座力同時可深插XBRECR173指引導(dǎo)管的選擇和操作技術(shù)課件174MedtronicRBU（Rightbackup)對側(cè)壁支撐適合開口平行或向下RCA通常插入10-12mm介于MAC和Amplatz之間通常使用RBU3.5MACMedtronicRBU（Rightbackup)對175Amplatz導(dǎo)管

良好的同軸和被動支持力，可用于多數(shù)起源異常冠狀動脈。根據(jù)L段長短分為AL0.75、AL1、AL1.5、AL2、AL3、AL4根據(jù)R段的長短分為AR1、AR2Amplatz導(dǎo)管176指引導(dǎo)管的選擇和操作技術(shù)課件177第二彎曲與冠狀竇及對側(cè)壁貼合，多點支撐AL2用于LCAAL1、0.75用于RCAAL第二彎曲與冠狀竇及AL178AR第二彎曲小限制器械通過支撐力弱僅用于“牧羊鉤”樣RCAAR第二彎曲小179進(jìn)出導(dǎo)管時需注意：1、當(dāng)Amplatz導(dǎo)管的“L”或“R”段位于冠狀動脈開口水平線上方時，可直接撤出或深插導(dǎo)管。進(jìn)出導(dǎo)管時需注意：1802、當(dāng)“L”或“R”段位于冠狀動脈開口水平線下方時，切忌直接后撤導(dǎo)管，應(yīng)推送導(dǎo)管，以底部為支撐點，使導(dǎo)管尖端后退，離開冠脈開口，再旋轉(zhuǎn)導(dǎo)管。推送旋轉(zhuǎn)2、當(dāng)“L”或“R”段位于冠狀動脈開口水平線下方時，切忌直接181短頭Amplatz導(dǎo)管標(biāo)準(zhǔn)短頭刮傷主動脈竇情況大大降低，造成靶血管撕裂、夾層可能降到最低入冠不深，幾乎沒有嵌頓現(xiàn)象、短頭Amplatz導(dǎo)管標(biāo)準(zhǔn)短頭刮傷主動脈竇情況182其他導(dǎo)引導(dǎo)管主要適用于向下的冠脈開口，可用于LCA和RCA。MP其他導(dǎo)引導(dǎo)管主要適用于向下的冠脈開口，可用于LCA和183

向上開口RCA和橋血管支撐力介于JR和Amplatz之間第一個彎較直，便于輸送器械

HSII用于正常直徑主動脈,HSI用于窄主動脈HSIII用于寬主動脈向上開口RCA和橋血管184Medtronic主要用于開口向上血管Medtronic主要用于開口向上血管185導(dǎo)引導(dǎo)管選擇同軸導(dǎo)引導(dǎo)管選擇同軸186同軸不良引起冠脈開口損傷同軸不良引起冠脈開口損傷187指引導(dǎo)管的選擇和操作技術(shù)課件188型號選擇開口高，選小號開口低，選大號型號選擇開口高，選小號189LCA導(dǎo)引導(dǎo)管選擇JL4開口高或主動脈根部小，可用JL3.5LM短，用短頭扭曲、鈣化、閉塞用Amplatz或ExtrabackupLCA導(dǎo)引導(dǎo)管選擇JL4190RCA導(dǎo)引導(dǎo)管選擇JR4開口向上，用Amplatz或HockeystickRCA導(dǎo)引導(dǎo)管選擇JR4191JL3.5開口向上或水平JL3.5開口向上或水平192冠脈起源異常導(dǎo)管選擇左冠口起源于右冠竇，選JR4或Amplatz右冠起源于左冠竇，選Amplatz或JL

升主動脈造影或CTA有幫助LCA起源右冠竇冠脈起源異常導(dǎo)管選擇左冠口起源于右冠竇，選JR4或Ampl193三維導(dǎo)管在不同軸向上進(jìn)行各種彎曲、形狀的設(shè)計如3DRC(Mdetronic)導(dǎo)管。三維導(dǎo)管在不同軸向上進(jìn)行各種彎曲、形狀的設(shè)計如3DR194SherpaNXActive3DRCA螺旋狀尾端第2、3彎頂在主動脈壁提供強支撐0.032inch導(dǎo)絲引導(dǎo)進(jìn)入后順時針或逆時針旋轉(zhuǎn)SherpaNXActive3DRCA螺旋狀尾端195AP-Cranial見RCA起源于左竇AP-Cranial見RCA起源于左竇196LAO見RCA起源異常LAO見RCA起源異常197橋血管導(dǎo)引導(dǎo)管選擇靜脈橋血管導(dǎo)管選擇常憑經(jīng)驗

CTA或升主動脈造影有幫助橋血管導(dǎo)引導(dǎo)管選擇靜脈橋血管導(dǎo)管選擇常憑經(jīng)驗198LCB

(Leftcoronarybypass)/RCB(Rightcoronarybypass)導(dǎo)引導(dǎo)管LCB(Leftcoronarybypass)199右冠橋血管右冠橋血管多起源于主動脈根部上方2-3cm的前壁，開口多向下，選擇MP、Amplatz或RCB。右冠橋血管右冠橋血管多起源于主動脈根部上方2-200左冠橋血管前降支和回旋支橋血管開口起源于右冠橋上側(cè)方，選擇JR、LCB、HockeyStick、Amplatz或MP。左冠橋血管前降支和回旋支橋血管開口起源于右冠橋上201開口如無明顯成角，用JR4或LCB明顯成角者用專用導(dǎo)管（IMA)可選擇左側(cè)橈動脈入路LIMA橋血管IMA開口如無明顯成角，用JR4或LCBLIMA橋血管IMA202LCBIMAJRLCBIMAJR203需要更大支持力怎么辦？更大直徑深插（頭端較直、較細(xì)導(dǎo)管更易深插，且可減少對冠脈損傷）

子母導(dǎo)管需要更大支持力怎么辦？更大直徑204HeartrailII(Terumo,Japan)long(120cm)5Frcatheter(13cmverysoftendportion)

Absenceofcurveandtheflexibilityofitstippermitthe“child”cathetercoaxialwiththetargetvessel,minimizingtheriskofdissection.5in6guidingcathetertechniqueInnercatheterHeartrailII(Terumo,Japan)5205Filledwithwaterthatwaskeptat37°C5mm/sFilledwithwaterthatwaskep206Switchingto5-in-6systemSwitchingto5-in-6system207CoronaryarteryinjuryDeep-vesselengagementcanbefacilitatedbypassageofaballooncatheter

AirembolismCoronaryarteryinjury2087FAL-1;3.5mmballoon7FAL-1;3.5mmballoon209指引導(dǎo)管的選擇和操作技術(shù)課件210(Goodman,Japan)(Goodman,Japan)211ThelumensizeoftheaspirationcatheterasthesizeofSESislimitedto3.0mm.Thelumensizeoftheas212GuideLinercath

Rapidexchange

Flexibleyellow20cmstraightextensionconnectedtoastainless-steelpushtubeResultsinanI.D.approximately1Fsizesmalleravailableinthreesizes:6F,7Fand8FGuideLinercathRapidexchang213指引導(dǎo)管的選擇和操作技術(shù)課件214指引導(dǎo)管的選擇和操作技術(shù)課件215指引導(dǎo)管的選擇和操作技術(shù)課件216Notrecommenditsuseintargetvesselsof<2.5mmdiameterNotrecommenditsuseintarge217

Softertipandhydrophiliccoatingoninsideandoutside.5-FrST01hasthecoatingonlyontheinside.CatheterizationandCardiovascularInterventions76:919–923(2010)(Terumo,Japan)Softertipandhydrophilicco218KIWAMIST01KIWAMIST01219Backupsupport

ofGCCircCardiovascInterv.2011Apr1;4(2):155-61BackupsupportofGCCircCardi2205-in-6systemExtending≥3cm,thebackupsupport>7FGC5-in-6system2214-in-6systemExtending≥5cm,thebackupsupportsigni?cantlyincreasedbutstill<7FGC4-in-6system222TrackabilityofGCUsingballoon-anchoringtechnique5Fchildcathetercouldbeadvancedto13.0cm,whereasthe4Fchildcathetercouldbeadvancedto15.0cm(P<0.005).TrackabilityofGCUsingballo223Provided>90%successratefor51lesionsinwhichconventionaltechniqueshadfailed.Successmaybecontributed,inmostpart,bythe

trackabilityofthe4Fchildcatheter.Doesnotusuallycompromisethecoronaryflow.Provided>90%successratefor224Peripheralballoonanchormethod

Balloonusedforpredilatationtothemostdistalportionofthelesion.In?atedandusedastheanchorKIWAMIisinsertedslowlytowardin?atedanchoringballoon.

NottodilatetheballoonatthehealthyportionPeripheralballoonanchormeth225Cypher(3.0×18mm)Cypher(3.0×18mm)2265-FrST01allowsanyBMSandDESKIWAMIeffectiveforstentswithadiameterupto3.0mmforCypherandTAXUSLiberte,3.5mmforEndeavor

MostofBMScanbedeployedusingKIWAMIexceptDRIVER(Medtronic)5-FrST01allowsanyBMSand227經(jīng)橈動脈PCI導(dǎo)引導(dǎo)管選擇和經(jīng)股動脈基本原則一致右側(cè)橈動脈導(dǎo)管型號比股動脈小半號，左側(cè)和股動脈相同經(jīng)橈動脈PCI導(dǎo)引導(dǎo)管選擇和經(jīng)股動脈基本原則一致228ComparingthebackupforcebetweenTFIandTRIitwasfoundtobe60%greaterinTFIwitha

JLcatheter,and8%greaterinTFIwithabackup(EBU/XB)typecatheter.

JInvasiveCardiol.2005Dec;17(12):636-41Comparingthebackupforcebet229theIkariL(IL)cathetergeneratedasimilarbackupforcebetweenTRIandTFI.特有的第1彎曲利用右鎖骨下動脈和無名動脈間夾角提供強支撐力JInvasiveCardiol.2005Dec;17(12):636-41經(jīng)橈動脈PCI專用導(dǎo)引導(dǎo)管theIkariL(IL)cathetergene230JLILJRIRJLILJRIR231Fajadet導(dǎo)管JFLJFR(France)Longtip設(shè)計提供良好支撐力和同軸性。Fajadet導(dǎo)管JFLJFR(France)Longti232MUTA-L/RMUTAL導(dǎo)管和JL導(dǎo)管相似，但支撐力比后者強，MUTAR導(dǎo)管彎曲是一種三維設(shè)計，有MR2和MR3兩種，MR2最常使用。MUTA-L/RMUTAL導(dǎo)管和JL導(dǎo)管相似，但233適合右側(cè)橈動脈入路，可用于左右冠和靜脈橋，較Judkins導(dǎo)管同軸性和主、被動支撐力好，易于操控，但較long-tip導(dǎo)管支撐力差。左右共用導(dǎo)引導(dǎo)管AMI病變,直接使用節(jié)省時間KIMNY?Curve適合右側(cè)橈動脈入路，可用于左右冠和靜脈橋，較Judki234RadialBrachial(Cordis)

3個彎度設(shè)計；適于水平或開口向下病變可以深插；左右橈動脈入路均可。RadialBrachial(Cordis)3個235RadialRunway適合右側(cè)橈動脈入路，可用于左右冠和靜脈橋，結(jié)構(gòu)特點類似與KIMNY。分為標(biāo)準(zhǔn)、短頭和高位開口頭。RadialRunway適合右側(cè)橈動脈入路，可用于左236Barbeau導(dǎo)管Barbeau導(dǎo)管237Male（mm）Female（mm）國外3.1±0.6

2.8±0.6

魏盟2.7±0.4

2.3±0.4

賈三慶2.65±0.60

2.20±0.49

RadialarterydiameterMale（mm）Female（mm）國外3.1±0.62.238radialarteryinternaldiameter/

sheathexternaldiameter4%inpatientswithratio>113%inpatientswithratio<1Thedosageofheparin,thediameterofradialarteryandthepost-procedurecompressionpressureandtimewere

independentriskfactorsforRAOCathetCardiovascDiagn1997;40:156–158

radialarteryinternaldiamete239Radialarterydiameter6Fsheathexternaldiameter=2.62mmRadialarterydiameter6Fsheat240MMainprox.firstAMainAccrosssidefirstDDistalfirstSSidebranchfirstExtendedVSkirtPMstentingMBstentingacrossSBMBstenting+kissingMBstenting+SBballoonElectiveTstentingInternalcrushCulotteTAPDMstentingProvisionalSKSVstentingSKSTrouserlegsandseatSBostialstentingSBminicrushSBcrushSyst.TStentingMinicrushCrushAfterballoon2stents3stents1ststentSkirt+DMSkirt