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
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
课件
Coronary Anomaly
• Excessively obese patient • Radial approach is
preserved for cardiac surgeon
课件
Brachial Access Disadvantages
• More vascular complication (Thromboembolism Hematoma) than radial 2-3%
• TRA improves the comfort of the patient. • TRA allows the use of most current devices
and technique. • TRA requires learning
课件
课件
Brachial Artery Puncture
课件
Brachial Access Indication
• Femoral or radial approach is not available
• Femoral approach is dangerous ( aortic aneurysm )
• Unaccessible IMA by femoral approach
课件
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
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
课件Leabharlann 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
Complex anatomy
课件
Complex anatomy
课件
Consensus on radial access
• TRA is an elegant, enthusiastic, profitable and reliable technique.
• TRA provides the lowest access site complication rate.
的风险 导管直接进出血液循环系统，有感染风险 需使用对比剂，有过敏和对比剂肾病风险
因此，规范操作十分课件重要
课件
课件
Left coronary distribution
Dominant LCX
课件 Wrap-around LAD
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
冠脉造影的规范操作
中国医学科学院 阜外心血管病医院
杨跃进
2009年介入沙龙（CISC 2009） 北京 09-2-20
课件
冠脉造影
仍是诊断CHD的“金标准” 是PCI操作技术的基础 经动脉系统操作：有血栓栓塞风险 导管进入冠脉内：有损伤冠脉口的风险 需引导导丝前引，有损伤血管的风险 需穿刺外周动脉、置入或拔出鞘管，有出血、血肿
GP2b/3a)
Patient to avoid • Shock • Raynaud’s, Buerger’s disease • Small artery even with normal Allen test
课件
Radial artery puncture
课件
Complex anatomy
课件
Anterior Superior Iliac Spine Inguinal Liagment
Pubis
课件
How to do a proper groin stick?
Good puncture
High Puncture
课件
Pros and cons for radial approach
• Advantages: • The lowest access site complication rate. • Early ambulation and early discharge. • Lower procedural cost.
• Disadvantages: • Technically more difficult.
课件
To use radial or not?
Patient selection • Obese ,elderly and patients with PVD • Patients with bleeding risk ( lytic, on coumadin,
课件
冠脉造影的基本步骤（2）
穿刺外周动脉，插入鞘管 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
课件
Seldinger technique
课件
• The maximal inguinal pulsation is over the CFA in 90% of cases
• Hard to compress( between the head and biceps)
• Nerve injury (median nerve is in the bundle)
课件
ACCESS: A Randomized Comparison of PTCA by the Radial, Brachial, and Femoral
• Fluoroscopically, the medial aspect of the femoral head marks the CFA. Puncture at this site will enter the CFA in 80% of cases
• The midpoint between the anterior superior iliac spine and the pubis located the CFA in most patients