1、經(jīng)橈動(dòng)脈入路行全腦血管造影,1,1989年加拿大醫(yī)生Campeau 首先報(bào)道應(yīng)用 橈動(dòng)脈穿刺進(jìn)行冠狀動(dòng)脈造影取得成功，在心 血管介入診療中逐漸發(fā)展 。 優(yōu)點(diǎn)：表淺，止血容易，并發(fā)癥少； 無(wú)需長(zhǎng)時(shí)間臥床，縮短留院時(shí)間，節(jié)省費(fèi)用； 患者易接受 橈動(dòng)脈穿刺技巧和血管動(dòng)脈造影技術(shù)。,2,適應(yīng)癥（Indications）,(a) 隨診（imaging follow-up） ; (b) 門診患者（cerebral angiography on an out-patient basis）; (c)較差的股動(dòng)脈入路 （ poor femoral access）; (d) 應(yīng)用抗血小板或抗凝治療患者（patie

2、nts on antiplatelets or anticoagulation therapy）,3,禁忌癥橈尺動(dòng)脈側(cè)支循環(huán)不良,Allen試驗(yàn) 5秒,其它： 橈動(dòng)脈難觸及；身材矮小女性橈動(dòng)脈較細(xì)； 頭臂干或鎖骨下動(dòng)脈嚴(yán)重疾??； 穿刺部位嚴(yán)重瘢痕等,4,橈動(dòng)脈血氧監(jiān)測(cè),The arterial waveform and arterial O2 saturation (SaO2) were checked via a pulse oximeter applied to the thumb.,5,橈動(dòng)脈穿刺技術(shù),6,橈動(dòng)脈解剖定位,7,橈動(dòng)脈穿刺和置入動(dòng)脈鞘操作難點(diǎn),較細(xì)小，易痙攣，不易穿刺成功

3、； 周圍支撐組織少，有高血壓和動(dòng)脈樣硬化時(shí)易滑動(dòng)； 有分支和走向解剖變異。,8,穿刺前仔細(xì)捫診橈動(dòng)脈了解其走向、血管彈性、搏動(dòng)情況 Allen試驗(yàn)或橈動(dòng)脈血氧監(jiān)測(cè) 開始注射麻藥不宜過(guò)多，0.3-0.5ml皮下浸潤(rùn) ； 專用的橈動(dòng)脈穿刺針：Cordis公司的空心鋼針和Terumo公司的套管鋼針 21-G 穿刺成功后退針應(yīng)緩慢； 導(dǎo)絲和動(dòng)脈鞘管進(jìn)入時(shí)應(yīng)無(wú)阻力，若稍有阻力，則應(yīng)在透視下操作切忌粗暴推送 。,9,穿刺點(diǎn)選擇,橈動(dòng)脈 過(guò)于靠近遠(yuǎn)端，誤入分支血管； 過(guò)于靠近近心端，增加穿刺的難度 穿刺失敗，向近心端移重新選擇穿刺點(diǎn)。 穿刺點(diǎn)一般在橈骨莖突近端1cm處：走行較直、相對(duì)表淺，穿刺容易成功，分支

4、相對(duì)較少，穿刺誤入分支血管的幾率較小。 但在少數(shù)橈動(dòng)脈迂曲、變異，穿刺點(diǎn)的選擇應(yīng)因人而異。理想的穿刺點(diǎn)應(yīng)選擇在橈動(dòng)脈走行較直且搏動(dòng)明顯的部位。,10,局麻,建議應(yīng)用“兩步法”給予局麻藥物，即穿刺前皮下少量注射麻藥，穿刺成功后在鞘管置入前再補(bǔ)充一定劑量的麻醉藥物。但在注射麻醉藥物時(shí)進(jìn)針不宜過(guò)深，以免誤傷橈動(dòng)脈。,11,穿刺技巧“The first is the best ”,腕部墊高，腕關(guān)節(jié)處于過(guò)伸狀態(tài) 穿刺者左手指輕放于患者橈動(dòng)脈搏動(dòng)最強(qiáng)處，指示患者橈動(dòng)脈的走行方向。避免按壓過(guò)度，會(huì)造成橈動(dòng)脈遠(yuǎn)端的血流受阻，人為增加了穿刺的難度。 進(jìn)針角度一般3045，但對(duì)于血管較粗或較硬者，進(jìn)針角度應(yīng)稍大；

5、而對(duì)于血管較細(xì)者進(jìn)針角度應(yīng)略??； 針尾部見回血，再前送穿刺針少許后，套管針穿刺者，應(yīng)先退出針芯后再回撤套管，注意退出針芯時(shí)確保固定套管位置，至針尾部噴血后再送入導(dǎo)絲，不能有阻力。 如進(jìn)針后未見針尾部回血，可用左手食指判斷此時(shí)穿刺針與橈動(dòng)脈的位置關(guān)系，再回撤穿刺針至皮下，調(diào)整針尖方向后再次進(jìn)針。,12,送入導(dǎo)絲,穿刺針尾端噴血良好，固定針柄以確保穿刺針位置不動(dòng)，同時(shí)右手送入導(dǎo)絲，動(dòng)作應(yīng)輕柔 遇到阻力應(yīng)停止前送導(dǎo)絲，可部分回撤導(dǎo)絲后，改變穿刺針的角度或旋轉(zhuǎn)穿刺針調(diào)整導(dǎo)絲的前進(jìn)方向后再次試送導(dǎo)絲，切忌強(qiáng)行推送導(dǎo)絲，誤傷小分支導(dǎo)致前臂血腫的發(fā)生。通常情況下要求前送導(dǎo)絲至少應(yīng)達(dá)到尺骨鷹嘴水平后再沿送鞘管

6、。,13,置入鞘管,置入鞘管前，需在穿刺部位補(bǔ)充麻醉藥。動(dòng)脈鞘管表面附有親水涂層材料，降低鞘管送入時(shí)的摩擦力，防止橈動(dòng)脈痙攣發(fā)生。 置入鞘管后一同撤出擴(kuò)張管及導(dǎo)絲。如能經(jīng)側(cè)管順利回血，可判定鞘管位于血管真腔，橈動(dòng)脈穿刺成功。,A 5-F introducer sheath was inserted into the radial artery.,14,注意,動(dòng)脈鞘連接生理鹽水過(guò)多的沖洗，會(huì)導(dǎo)致動(dòng)脈痙攣，應(yīng)避免。肝素20003000IU。 若出現(xiàn)痙攣，可注入硝酸甘油（150250ug）或維拉帕米（ 150250ug）。,15,橈動(dòng)脈穿刺過(guò)程中常見的問(wèn)題及處理,同一部位反復(fù)穿刺不成功 穿刺針刺入橈

7、動(dòng)脈，但穿刺針尾部血流不暢 穿刺針回血良好，但送入導(dǎo)絲時(shí)阻力較大 置入鞘管時(shí)阻力較大,16,穿刺不成功,未能刺中橈動(dòng)脈：針對(duì)不同情況改變穿刺手法后進(jìn)針。 例如：較硬易于滾動(dòng)的橈動(dòng)脈，搏動(dòng)很強(qiáng)，但難以刺中 選擇裸針穿刺更具優(yōu)勢(shì)，加大進(jìn)針角度和速度 ； 橈動(dòng)脈較細(xì)、搏動(dòng)較弱 選擇套管針穿刺進(jìn)入真腔的成功率高，小角度穿刺，緩慢進(jìn)針 。 橈動(dòng)脈走行迂曲：更換穿刺點(diǎn)至走行較直部位后再行穿刺； 橈動(dòng)脈發(fā)生痙攣：橈動(dòng)脈的搏動(dòng)減弱甚至消失。盲目穿刺可能會(huì)進(jìn)一步加重橈動(dòng)脈痙攣，等橈動(dòng)脈搏動(dòng)恢復(fù)后再行穿刺；（應(yīng)用解痙藥） 穿刺局部形成血腫：應(yīng)避開血腫部位后重新選擇穿刺點(diǎn)。,17,穿刺針尾血流不暢或送入導(dǎo)絲阻力較大

8、,針尖斜面未完全進(jìn)入血管腔：針尖的位置可能位于前壁或后壁調(diào)整穿刺針的深度和進(jìn)針角度使針尖完全進(jìn)入血管腔。 橈動(dòng)脈痙攣不噴血，但導(dǎo)絲?？身樌八?，不會(huì)對(duì)橈動(dòng)脈入路的建立帶來(lái)太大的障礙。 進(jìn)入分支：調(diào)整穿刺針位置后仍無(wú)法順利前送導(dǎo)絲常提示此種可能，穿刺點(diǎn)過(guò)于靠近腕部時(shí)多見，常需要向近心端前移穿刺部位后再次進(jìn)針。 橈動(dòng)脈迂曲：透視下調(diào)整導(dǎo)絲的前進(jìn)方向后再試行通過(guò)彎曲段血管，必要時(shí)可能需要更換穿刺部位。,18,共有并發(fā)癥,穿刺部位出血、血腫及假性動(dòng)脈瘤 動(dòng)靜脈瘺 動(dòng)脈夾層、動(dòng)脈血栓、閉塞和穿刺動(dòng)脈遠(yuǎn)端栓塞,19,橈動(dòng)脈途徑相關(guān)獨(dú)有并發(fā)癥,橈動(dòng)脈 特點(diǎn)：超聲測(cè)定直徑:平均2.600.41 mm, 82%

9、病人適合5F鞘管。 注意：老齡、高血壓患者橈動(dòng)脈迂曲，無(wú)名動(dòng)脈與主動(dòng)脈弓成銳角；0.4%2%右鎖骨下動(dòng)脈起源升主動(dòng)脈遠(yuǎn)端或水平型主動(dòng)脈弓后方。 約7%9%病人不適宜橈動(dòng)脈操作，強(qiáng)行操作會(huì)增加橈動(dòng)脈特有并發(fā)癥的發(fā)生。,20,獨(dú)有并發(fā)癥,橈動(dòng)脈痙攣：平滑肌受腎上腺受體控制，易痙攣。與緊張、反復(fù)穿刺、麻醉不充分、粗暴送入鋼絲和導(dǎo)管有關(guān)術(shù)前充分鎮(zhèn)靜、提高穿刺成功率、使用硝酸甘油或維拉帕米有效。 嚴(yán)重痙攣導(dǎo)致鞘管或?qū)Ч軣o(wú)法拔出避免強(qiáng)行，應(yīng)該在病人充分放松后延遲拔。 血腫：橈動(dòng)脈破裂血腫導(dǎo)致前臂擠壓綜合征，發(fā)生率低，但未及時(shí)減壓處理，可終身致殘。,21,前臂筋膜綜合征,在肢體骨和筋膜形成的間隔區(qū)內(nèi)，各種原

10、因造成組織壓上升，致血管受壓，血液循環(huán)障礙，肌肉、神經(jīng)組織嚴(yán)重供血不足，發(fā)生缺血壞死，最終導(dǎo)致 些組織功能損害，由此而產(chǎn)生的一系列癥候群，統(tǒng)稱為筋膜間隔區(qū)綜合征。 通常缺血30分鐘，即發(fā)生神經(jīng)功能異常；完全缺血1224小時(shí)后，則發(fā)生肢體永久功能障礙，出現(xiàn)肌肉攣縮、感覺異常、運(yùn)動(dòng)喪失等表現(xiàn)。典型者五“P”癥：由疼痛轉(zhuǎn)為無(wú)痛（Painless）;蒼白（Pallor）或紫紺，大理石花紋等;感覺異常（Paresthesia）；肌肉癱瘓（Paralysis），無(wú)脈（Pulselessness）。 預(yù)防方法：避免反復(fù)多次透壁穿刺，盡量小鞘管，導(dǎo)引鋼絲永遠(yuǎn)至于導(dǎo)管的前方，輕柔操作。,22,前臂水腫,長(zhǎng)時(shí)間過(guò)

11、度壓迫導(dǎo)致靜脈回流不暢， 尤其在合并前臂血腫時(shí)更易出現(xiàn)。 一般2小時(shí)應(yīng)該明顯松解壓迫，避免大面積的壓迫橈動(dòng)脈周圍。,23,拔鞘,拔鞘后局部壓一小沙布球，彈力繃帶包扎：松緊適度，手腕制動(dòng)6小時(shí)。觀察末梢血供情況（顏色、溫度）及患者感受，可每2小時(shí)松解一次。,24,Loop formation at the radial artery in a 75-year-old man interfered with insertion of the guide wire of the introducer sheath,25,During guide wire insertion through the

12、radial artery, it entered the radial recurrent artery返動(dòng)脈, causing sharp pain in the forearm.,26,Thrombus migrating into the ulnar artery during DSA of the forearm artery performed at the end of the examination.,27,Ultrasonic assessment of vascular complications incoronary angiography and angioplasty

13、 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.,28,Limit

14、ations of Successive Transradial Approach in the Same Arm: The Japanese ExperienceCatheterization 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 thre

15、e to five times in most Japanese patients.,29,全腦血管造影,30,主動(dòng)脈弓造影,豬尾導(dǎo)管置于升主動(dòng)脈內(nèi),31,Simmons導(dǎo)管使用法,Simmons導(dǎo)管有三型，即I、型(圖)。,32,有較長(zhǎng)的、開袢狀的兩個(gè)弧與兩個(gè)臂。I型的遠(yuǎn)側(cè)臂長(zhǎng)3.6cm，型遠(yuǎn)側(cè)臂為6.4cm，型為8.4cm。 根據(jù)主動(dòng)脈弓的直徑?jīng)Q定導(dǎo)管遠(yuǎn)側(cè)臂的長(zhǎng)度應(yīng)至少比要插管的血管水平處主動(dòng)脈的寬度稍長(zhǎng)，當(dāng)注射造影劑時(shí)導(dǎo)管才不會(huì)彈出血管。 主動(dòng)脈弓成袢方法：2種,33,成袢方法,2種： 降主動(dòng)脈成袢：較安全 升主動(dòng)脈成袢：用于迂曲、擴(kuò)張的主動(dòng)脈弓，導(dǎo)絲不能到達(dá)降主動(dòng)脈時(shí),34,A met

16、hod 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 cathet

17、er 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.,35,A method within the ascending aorta (Method 2). With very tortuous and

18、 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 t

19、he guide wire. The course of the catheter and wire is blurred due to the cardiac motion. (c) Finally the catheter curve is obtained.,36,(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,37,A. A 0.035-inch guide wire was passed though the radial

20、 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,38,When handling the catheter, the brain supplying arteries can be

21、 easily selected. A. L-CCAB. L-ICAC. R-CCAD. L-VA,39,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.,40,SimmonsIII導(dǎo)

22、管造影,41,注意,操作導(dǎo)管在透視下進(jìn)行：進(jìn)管、超選血管及撤管時(shí)；導(dǎo)絲輔助 Simmons導(dǎo)管獨(dú)特的頭端彎曲，應(yīng)注意避免損傷血管壁一般應(yīng)用導(dǎo)絲引導(dǎo)進(jìn)入血管； 難點(diǎn)：L-ICA,L-VA（角度）； 經(jīng)驗(yàn)：一般應(yīng)用 5F Simmons 導(dǎo)管 較易操作，不易紐結(jié)，尤其是血管迂曲者； 導(dǎo)管到達(dá)降主動(dòng)脈困難應(yīng)用豬尾導(dǎo)管長(zhǎng)交換導(dǎo)絲至降主動(dòng)脈，再將Simmons導(dǎo)管交換到位，可用方法1成袢。 少數(shù)可直接進(jìn)入右側(cè)頸總動(dòng)脈內(nèi)成袢,42,Transradial Approach for Diagnostic Selective Cerebral Angiography: Results of a Consecu

23、tive Series of 166 Cases.,AJNR Am J Neuroradiol 22:704708, April 2001,43,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 compli

24、cations. 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 t

25、his method.,44,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.,45,Routine t

26、ransradial 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%).,46,CONCLUSION: Transradial angiography is a useful tool for diagnostic and interventional neuroangiograp