5.第一对角支 16.房室结动脉
6.第二对角支 17.后降支
7.回旋支近段 18.左心室支
8.回旋支远段 19.右心室支
9.钝缘支
20.锐缘支
10.后降支
21.室间隔穿支
11.窦房结动脉 22.左心房支
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5
Coronary Anomaly
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6
规范操作：定义或原则？
定义？ 是将冠造风险降至最低甚至可避免的合理操作
Approaches
900 patients undergoing PTCA randomized to radial, brachial or femoral artery access site.
N=900
Radial (n=300 Brachial Femoral
) (n=300) (n=300)
• Hard to compress( between the head and biceps) • Nerve injury (median nerve is in the bundle)
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ACCESS: A Randomized Comparison of PTCA by the Radial, Brachial, and Femoral
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21
Brachial Access Indication
• Femoral or radial approach is not available
• Femoral approach is dangerous ( aortic aneurysm )
• Unaccessible IMA by femoral approach
• Disadvantages: • Technically more difficult.
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13
To use radial or not?
Patient selection • Obese ,elderly and patients with PVD • Patients with bleeding risk ( lytic, on
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16
Complex anatomy
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17
Complex anatomy
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18
Consensus on radial access
• TRA is an elegant, enthusiastic, profitable and reliable technique.
• TRA provides the lowest access site complication rate.
coumadin, GP2b/3a)
Patient to avoid • Shock • Raynaud’s, Buerger’s disease • Small artery even with normal Allen test
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14
Radial artery puncture
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15
Complex anatomy
• TRA improves the comfort of the patient. • TRA allows the use of most current devices and
technique. • TRA requires learning
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19
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20
Brachial Artery Puncture
• The midpoint between the anterior superior iliac spine and the pubis located the CFA in most patients
ቤተ መጻሕፍቲ ባይዱ
Anterior Superior Iliac Spine Inguinal Liagment
股动脉
桡动脉
肱动脉（应严格指征）
前送导管至升主动脉的根部
需导丝引导
避免操作阻力
避免进入沿途动脉分支
抽血排气，监测压力
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9
Seldinger technique
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10
• The maximal inguinal pulsation is over the CFA in 90% of cases
• Fluoroscopically, the medial aspect of the femoral head marks the CFA. Puncture at this site will enter the CFA in 80% of cases
冠脉造影的规范操作
a
1
a
2
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3
Left coronary distribution
Dominant LCX
a Wrap-around LAD
4
冠状动脉血管树解剖示意图
1.左主干
12.圆锥支
2.前降支近段 13.右冠状动脉近段
3.前降支中段 14.右冠状动脉中段
4.前降支远段 15.右冠状动脉远段
Pubis
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11
How to do a proper groin stick?
Good puncture
High
Puncture
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12
Pros and cons for radial approach
• Advantages: • The lowest access site complication rate. • Early ambulation and early discharge. • Lower procedural cost.
• Excessively obese patient
• Radial approach is preserved for cardiac surgeon
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22
Brachial Access Disadvantages
• More vascular complication (Thromboembolism Hematoma) than radial 2-3%
原则：需有效降低上述风险甚至潜在风险 穿刺血管损伤 沿途动脉损伤 冠脉损伤 心肌缺血 过敏 感染 血栓栓塞
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7
冠脉造影的基本步骤（1）
操作准备
消毒、铺巾、准备心电压力连接 穿刺、鞘管准备 导管（肝素水）冲洗 急救药物准备 三联三通准备
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8
冠脉造影的基本步骤（2）
穿刺外周动脉，插入鞘管
Successful Coronary Cannulation (%) 93.0 95.7 99.7