脑血管介入流程.ppt

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,*,全脑血管造影,-,流程与规范,马敏敏,南京军区南京总医院神经内科,南京大学医学院神经病学研究所,脑血管病的常用影像学方法,Radiography(X-Ray),Fluoroscopy(guided procedures),Angiography,Diagnostic,Interventional,Myelography,Ultrasound(US),Gray-Scale,Color Doppler,Computed Tomography(CT),CT Angiography(CTA),Perfusion CT,CT Myelography,Magnetic Resonance(MR),MR Angiography/,Venography,(MRA/MRV),Diffusion and Diffusion Tensor MR,Perfusion MR,MR Spectroscopy,Functional MR(fMRI),Nuclear Medicine,SPECT,PET,“Duplex”,目的,明确诊断,是否存在病变：与正常血管解剖相比较,病变部位及数目：,颈动脉系统,or,椎基底动脉系统？,颅内,or,颅外？,单发、串联,or,广泛？,病变性质：狭窄、夹层、动脉瘤、血管畸形,目的,指导治疗,制定方案：,血管内介入：选择器材、制定策略,药物,or,外科手术？,评价疗效,适应症,脑血管疾病,缺血性：动脉狭窄、闭塞,出血性：动脉瘤、动静脉畸形,其它：动静脉瘘、静脉窦血栓形成,颅内占位性病变：肿瘤、血肿,术后及侧支循环状态评估,禁忌症,碘过敏者,有严重出血倾向或出血性疾病,有严重心、肝或肾功能不全,脑疝、脑干功能衰竭,生命体征不稳定者,穿刺处皮肤或软组织感染,术前评估,了解病情,现病史、既往史、药物过敏史,目前用药情况,神经系统检查,术前评估,头颈部听诊,颈动脉分叉部（颈动脉）：甲状软骨,or,第,4,颈椎水平,锁骨上窝（锁骨下动脉）,眼眶部（眼动脉）,头后部下方（椎动脉）,缺血性脑血管病血管内治疗手册,术前评估,血管搏动（食指及中指、双侧对比）,桡动脉、股动脉、足背动脉,血压测定,双侧收缩压和舒张压差,20mmHg,术前评估,实验室检查,血常规、肝肾功、凝血常规、血糖、,传染病四项,心电图,术前评估,头颅,CT,MRI,术前评估,头颅,MRA,颈部,CTA,术前评估,TCD,颈部超声,术前准备,备皮,更换手术衣,建立静脉留置通道,术前将检查资料（,CT,、,MRI,等）带到导管室,术前准备,禁食,镇静剂：鲁米那,0.2,肌注,术前有效控制血压,患者教育,简要介绍操作过程,造影剂注入时的感受,运动伪影可影响造影质量,术前准备,器材,穿刺器械：穿刺针、血管短鞘（,4-6F,）、短导丝、刀片、注射器（,5ml,、,10m1,各,1,支）,造影器械：,超滑导丝,0.035/150cm,、高压注射器、造影管,(Pigtail,、,Headhunter,、,Simmons),、,10m1,注射器,1,支、,2,个三通接头、,1,个,Y,型阀、输液导管及造影连接管各,1,付,所有器械必须用肝素生理盐水冲洗，导管及鞘在进入血管前必须充分冲洗排气,术前准备,药品：,1%,利多卡因、非离子性造影剂,肝素生理盐水（,NS 500ml+,肝素,2000u,）,肝素、尿激酶、,rtPA,阿托品、多巴胺、压宁定、硝酸甘油、,尼莫通,地塞米松、肾上腺素,罂栗碱,消毒,术者：,0.05%,碘伏,3,遍,范围：双手、前臂、肘上,10cm,顺序：指尖肘上,注意：不可遗漏，若双手被污染需重新消毒,消毒,患者：,0.05%,碘伏,3,遍,范围（双侧）：,上界：平脐 下界：大腿上,1/3,外界：腋中线延线 内界：大腿内侧,顺序：以穿刺点为中心，由内向外,注意：不可遗漏，每次消毒范围不可超越前次,铺巾，穿手术衣，戴无菌手套,肝素盐水冲洗穿刺针、动脉鞘、泥鳅导丝、猪尾管，浸透,J,形导丝,冲洗并连接导管、,Y,形阀、三通,抽吸,2%,利多卡因,5ml,抽吸造影剂并接高压连接管,铺单,股动脉穿刺,股动脉穿刺,优先穿刺右股动脉,以右侧腹股沟与股动脉交界处沿股动脉向下,1,1.5cm,为穿刺点,穿刺针成角,30,45,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,股动脉穿刺,肝素化,置鞘成功后即刻肝素化,首剂肝素量,:60,90U/kg,1h,后给首剂,1/2,量，以后再,1h,给上次,剂量的,1/2,肝素盐水，接冲洗管,30,滴,/min,左右,持续冲洗,主动脉弓造影,评估路径,发现解剖变异,提示主动脉弓及弓上大动脉开口部位病变：狭窄、闭塞,双侧椎动脉是否对称，有无盗血,主动脉弓造影,将泥鳅导丝,0.035/150cm,及,Pigtail,导管送入升主动脉远端,回撤导丝，回抽,2ml,血后用肝素生理盐水冲洗导管,接造影连接管，透视下调整视野,左前斜,30,度造影,（流速,20ml/s,总量,30ml,）,回撤导管,主动脉弓造影,注意事项,接造影连接管时需注意接口处有无气泡,回撤导管时左手需固定血管鞘,主动脉弓,无名动脉,左侧锁骨下动脉,右锁骨下动脉,右颈总动脉,左颈总动脉,右颈内动脉,左颈内动脉,右椎动脉,左椎动脉,主动脉弓造影,主动脉弓造影,主动脉弓造影,主动脉弓造影,主动脉弓造影,颈动脉造影,沿导丝将导管送入颈总动脉近端,回撤导丝，回抽后用肝素生理盐水冲洗导管,调整视野,颅外：正位：脊柱位于屏幕正中,侧位：第三颈椎椎体位于屏幕正中,颅内：正位头位：头颅居中，上界平颅盖骨,侧位：上界平颅盖骨，左界平额骨前部,造影剂：流速,5ml/s,总量,8ml,(,超选,4ml/s,总量,6ml),颈动脉造影,观察内容,是否存在狭窄、闭塞及严重扭曲,侧支循环代偿情况,有无发育异常,是否存在动脉瘤、,AVM,、血管夹层等,颈动脉造影,注意事项,勿随意将导管头送入颈外动脉及颈内动脉,勿将导丝头送入颈内动脉,可行多角度投射造影,颈动脉造影,椎动脉造影,将导管沿导丝置于锁骨下动脉内椎动脉,开口处造影,回撤导丝，回抽后用肝素生理盐水冲洗,导管,椎动脉造影,调整视野,颅外：正位：导管头端距屏幕下界,2cm,脊,柱位于屏幕正中,侧位：脊柱位于屏幕正中,颅内：正位：头颅居中，上界平眶上缘,2cm,侧位：下界平第,2,椎体下缘，右界平,枕骨最后部,造影剂：流速,4ml/s,总量,6ml,椎动脉造影,观察内容,是否存在狭窄、闭塞及严重扭曲,侧支循环代偿情况,有无发育异常,是否存在动脉瘤、,AVM,、血管夹层等,椎动脉造影,注意事项,勿随意将导管头送入椎动脉内,若右锁骨下近端狭窄，可将导管置入头,臂干行右前斜头位造影,若考虑为偏心性狭窄，可行多角度投射,造影,椎动脉造影,造影中需注意的问题,全程肝素化,术中持续冲洗，注意排空管道和,Y,形阀内气体,导丝沿路径图推进，导丝头端不超出视野，导,丝一般不通过狭窄段,导管应尽可能沿导丝进退，以减少导管头对血,管壁的损伤，导管头端尽可能不触及血管壁，,导管一般不进入狭窄段和椎动脉内,造影中需注意的问题,各段脑供血动脉和颅内静脉窦不可遗漏,发现狭窄病变后，可多角度投照，找出狭窄切,线位放大投照,测量钢球尽可能靠近病变，并放在影像增强器,的中心，以保障测量准确,导管与导丝技术,导管：根据头端弯曲可分为单一弯曲导,管和复合弯曲导管,单弯导管：,Vertebral,导管（椎动脉造,影导管）和,MPA,导管（多功能造影导管）,复合弯曲导管：,Hunter-head,导管（猎,人头导管）、,Simmons,导管（西蒙管）及,Cobra,导管（眼镜蛇导管）,理想的导管,适宜的硬度、弹性、柔软性和扭控力，形状记忆好,管壁应光滑，表面摩擦系数小，跟踪性好,血管形成性能应控制在最低范围,导管材料无活性、无毒、无抗原性，耐高温或消毒液的浸泡,良好的不透,X,线性能,Diameter sizes,采用法制标准,French(F),Corresponds to,outer diameter,1F=0.33,5,mm,=0.013inc.,Indicated on the hub,Catheter sizes&Colors,Red4F,Grey5F,Green6F,on hub!,Orange7F,Blue8F,Black9F,All information on the hub,1-PSI(max),2-French size,3-Shaft length(usable),4-GW accept.,导管的选择,cobra,headhunter,simmons,导管技术,导管技术,Simmons,导管,Simmons,导管,Simmons,导管,Simmons,导管,导丝,常用的为直径为,0.035in,的亲水导丝（泥鳅导,丝或超滑导丝）,按照导丝硬度分为普通造影导丝（,Angio,）,和硬导丝（,Stiff,）,按照导丝长度分为,150cm,和,260cm,（或,300cm,）规格（主要用于交换导管，故又称,交换导丝）,导管与导丝技术,导丝的操控,颈动脉支架置入术,SAPPHIRE,研究,CEA,高危患者保护装置下支架置入与血管成形试验（,stenting,and angioplasty with protection in patient at high,rish,for,endarterectomy,SAPPHIRE,）,第一项在有症状或无症状颈动脉狭窄患者中比较,CAS,和,CEA,疗效的多中心随机对照研究,介入器材,ANGIOGUARD,血栓保护装置,Cordis PRECISE,支架,入选病例被随机分入使用保护装置的支架介入术组(,n=159),和内膜切除术组(,n=151),对于风险过高的病人，由介入科医生、血管外科医生和神经科医生组成的医生小组共同决定进入注册组,CONSENSUS,一致同意,RANDOMIZED,PROSPECTIVE,随机，前瞻性,3,10(12 month),Stenting,支架组=15,9,/,CEA,=151,STENT,REGISTRY,支架注册,40,7,SURGICAL,REFUSAL,外科拒绝,SURGICAL,REGISTRY,外科注册,7,INTERVENTIONAL,REFUSAL,介入拒绝,医生小组：神经科医生，外科医生，介入科医生,The SAPPHIRE Trial,SAPPHIRE(high-risk patients)30 days and 12 months results,SAPPHIRE(high-risk patients)30 days and 12 month results,“,Stented patients are now 12 months out from treatment,and their,MAE rate,continue to,be as good as,and in many ways better than,those for the surgically treated group.”,接受治疗12个月后，支架组病人不良事件的发生率相当于，甚至在很多方面，优于手术治疗组。,12 month Results:CAS vs.CEA,Overall MAE rate,总体主要不良事件发生率,11.9%vs.19.9%:,difference,显著差异,p=0.06,Death rate,死亡率6.9%,vs.12.6%:,double number of patients died in the CEA arm,外科组死亡人数比支架组多一倍,Stroke rate,中风发生率 5.7%,vs.7.3%:,30%more patients experienced a stroke in the CEA arm,外科组至少发生一次中风的病人数比支架组多30%,Major Ipsilateral Stroke rate,主要同侧大中风发生率,0.0%,vs.3.3%,was significant higher in CEA,外科组显著高于支架组，,p=0.03,MI(Q or non Q)rate,心梗发生率2.5%,vs.7.9%:,patients got 3 times more MI in the CEA arm,外科组发生心梗的病人数比支架组多三倍以上,Outcome of cranial nerve injury(30 days)30,天内颅神经损伤的发生率,0.0%,vs.5.3%:,was significant for CEA arm,外科组显著高于支架组，,p 0.01,结 论,ISC 2010,-CREST,CREST,设计,前瞻、多中心、随机对照试验，盲法判定,比较对于症状性和无症状性颈动脉狭窄患者是,CEA,还是,CAS,更好,每个中心团队包括神经科医生、介入医生、外科医生和研究协调员,80,患者分组和基本情况,CAS(n-1262),CEA(n,=1240),年龄,69,69,女性,36,34,无症状性,47,47,高血压,86,86,糖尿病,30,30,血脂异常,82,85,目前吸烟,26,26,心血管病,40,43,平均收缩压,mm,Hg,142,141,70%,狭窄的例数,85,87,症状性狭窄发病天数,20,25,81,主要终点,（,卒中、心梗、围手术期死亡加同侧卒中）,HR=1.11,95%CI 0.81-1.51,P=0.51,主要终点,:,围手术期事件,（,死亡、卒中、心梗）,HR=1.18,95%CI 0.82-1.68,P=0.38,围手术期卒中,卒中,HR=1.79,95%CI 1.14-2.82,P=0.01,心梗,HR=1.35,95%CI 0.54-3.36,P=0.52,围手术期颅神经麻痹,HR=0.07,95%CI 0.02-0.18,P0.0001,同侧卒中,HR=0.94,95%CI 0.50-1.76,P=0.85,结论,CEA,和,CAS,有相同的净预后，尽管各自风险不同，但是,CAS,有较低的心梗发生，,CEA,有较低的卒中风险,年轻患者,CAS,获益多，年长患者,CEA,获益多,有经验的中心,CEA,和,CAS,显示更低的围手术期并发症，有更杰出的预后,未来，,CEA,和,CAS,是预防卒中有用的工具,适应症,无症状血管狭窄程度大于,70,，有症状,(TIA,或中风发作,),血管狭窄程度大于,50,狭窄程度小于,50,，但有溃疡性斑块形成,某些肌纤维发育不良者，大动脉炎稳定期有局,限性狭窄,放疗术后或内膜剥脱术后、支架术后再狭窄,由于颈部肿瘤压迫等受压而导致的狭窄,急性动脉溶栓后残余狭窄,禁忌症,3,个月内有颅内出血，,2,周内有新鲜脑梗塞,不能控制的高血压,对肝素、阿司匹林或其他抗血小板类药物有禁忌者,对造影剂过敏者,颈内动脉完全闭塞,伴有颅内动脉瘤，并且不能提前或同时处理者,在,30,天以后预计有其他部位外科手术者,2,周内曾发生心肌梗塞,有严重心、肝、肾疾病,术前准备,术前,6,小时禁食水,术前,6,小时之内碘过敏试验,双侧腹股沟区备皮,术前,35,天口服抗血小板药物：氯吡咯雷,75mg+,阿司匹林,100mg,颈部血管超声，,TCD,评价,局部脑血流评价,(,核磁共振灌注、,PET,、,CT,灌注或,SPECT,其中一项或以上,),全脑血管造影或,CTA,、,MRA,狭窄程度的评价,参照,NASCET,标准,狭窄率,%=,（,1-A/B,）,100,狭窄程度,轻度（,0%-29%,）,中度（,30%-69%,）,重度（,70%-99%,）,操作方法,经股动脉采用,Seldinger,技术穿刺，一般放置,8F,导管鞘，导管鞘连接加压盐水持续滴注冲洗,肝素（,50100 U/kg),导引导管后面接,Y,阀或止血阀并与加压盐水连接，在,0.035”,泥鳅导丝小心导引下放在患侧颈总动脉，头端位置距离狭窄约,35cm,。过度迂曲的颈总动脉可以使用交换导丝将导引导管交换到位,通过导引导管造影测量狭窄长度和直径选择合适支架，并行患侧狭窄远端颅内动脉造影以备支架术后对照,操作方法,通过导引导管将保护装置小心穿过狭窄并将其释放在狭窄远端,45cm,位置，撤出保护装置外套。支架置入前静脉给予阿托品,0.5mg,以防心动过缓及低血压,置入支架，造影检查支架术后残余狭窄管径，酌情作支架内后扩,如果狭窄特别严重，或血管弯曲影响保护伞的安全通过，可选择合适的球囊行预扩,最后撤出保护装置，行颈部以及患侧颅内动脉造影与术前对比,Aguard,Deploy,Mov,Pic.mpg,脑保护装置,脑保护装置,支架类型,球扩式支架,Palmaz,Stent,(,Cordis,),自膨式支架,Carotid,Wallstent,(Boston Scientific),PRECISE,(,Cordis,),Protg,(ev3),Acculink,(Abbott,）,自膨式支架,雕刻支架,编织支架,编织支架,优点,支撑力更大,不易塌陷,柔韧性更强，表面光滑，易于球囊通过,网孔密集，限制斑块脱落,可重新定位、再次释放,编织支架,不足,短缩、不易精确定位,拉伸颈动脉、上端扭曲、成角,凹凸不平处贴壁欠佳,雕刻支架,优点,顺应性好，适应不同形状而不造成血管强直,贴壁性好，不易造成死腔,基本无缩短，定位和选择长度较精确,不足,后扩时有连接点断裂的风险,支架选择,支架直径,(,完全张开,),必须至少比最大的目,标血管大,1,mm,目标血管：,CCA,支架长度：两端至少超过狭窄,0.5,1 cm,，,并覆盖“健康,”,动脉,如果颈动脉狭窄累及分叉处，则支架至少,要放,1,cm,在颈总动脉,支架选择,颈动脉迂曲不明显及狭窄边缘较光整时，选用,Wallstent,或雕刻支架均可,颈动脉迂曲较明显时，雕刻支架的柔顺性和贴壁性较好,高危斑块（软斑块）宜选用,Wallstent,如果必须处理颈外动脉病变，则只能选用,Wallstent,，,以便在,Wallstent,的网眼中进行扩张,颈动脉支架置入术,颈动脉支架置入术,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Terumo guidewire,0.035”,100cm,Headhunter,5F Tempo,200cm,INTRODUCE GUIDEWIRE AND INTRODUCER SHEATH,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Terumo guidewire,0.035”,100cm,Headhunter,5F Tempo,200cm,INTRODUCE GUIDEWIRE AND INTRODUCER SHEATH,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,SELECTIVE CATHETHETERISATION OF ECA,Terumo guidewire,0.035”,100cm,Headhunter,5F Tempo,200cm,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Headhunter,5F Tempo,200cm,EXCHANGE,GUIDEWIRE,Terumo guidewire,0.035”,100cm,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Headhunter,5F Tempo,200cm,EXCHANGE,GUIDEWIRE,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Headhunter,5F Tempo,200cm,EXCHANGE,GUIDEWIRE,Amplatz Emerald,0.035”,260cm,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Amplatz Emerald,0.035”,260cm,EXCHANGE,INTRODUCER SHEATH,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Amplatz Emerald,0.035”,260cm,Brite Tip Sheath,7F,80cm,EXCHANGE,INTRODUCER SHEATH,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,REMOVE,GUIDEWIRE,Carotid Artery Disease:,Carotid Angioplasty-ProcedureHints,At this stage:,Never cross the lesion in the ICA,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,INTRODUCE,PROTECTION DEVICE,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Angioguard,0.014”,300cm,Brite Tip Sheath,7F,80cm,INTRODUCE,PROTECTION DEVICE,Angioguard Device:,Delivery Sheath Covering Filter,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,CROSS LESION WITH,PROTECTION DEVICE,Angioguard,0.014”,300cm,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip 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stent,7-8mm,30-40mm,Angioguard,0.014”,300cm,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,Smart,Carotid stent,7-8mm,30-40mm,RETRIEVAL,PROTECTION DEVICE,Angioguard,0.014”,300cm,Angioguard Device:,Capture Sheath Retrieving Filter,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,Smart,Carotid stent,7-8mm,30-40mm,RETRIEVAL,PROTECTION DEVICE,Angioguard,0.014”,300cm,Angioguard,Device:,Retrieved Basket,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,Smart,Carotid stent,7-8mm,30-40mm,ANGIOGRAPHIC,CONTROL,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,Smart,Carotid stent,7-8mm,30-40mm,ANGIOGRAPHIC,CONTROL,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Smart,Carotid stent,7-8mm,30-40mm,谢 谢,