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,*,Li Yue, M.D.,The First Affiliated Hospital of Harbin Medical University,指引导管的选择和操作技术,Li Yue, M.D.The First Affiliat,1,3000 B.C.,Egyptians,perform bladder,catheterizations using metal pipes.,400 B.C., Catheters fashioned from hollow,reeds and pipes are used in,cadavers,to,study the,function of cardiac valves,.,人类使用导管的历史,3000 B.C. Egyptians perform,2,1711, Hales conducts the,first cardiac catheterization of a horse,using,brass pipes, a,glass tube,and the,trachea of a goose,.,1711 Hales conducts the fir,3,1929年，德国外科医生,Werner Forssmann,将一根,导尿管插入自己心脏，这是插入人体心脏的第,一根导管。,Nobel Prize，1956,For his,pioneering efforts,.,1929年，德国外科医生Werner Forssmann将,4,1958, The,diagnostic coronary angiogram,the key to selective imaging of the heart is,discovered by Mason Sones.,1964,Transluminal Angioplasty, the concept,of remodeling the artery, is introduced by,Charles T. Dotter.,1958 The diagnostic coronar,5,1967年，,Melvin P. Judkins,设计冠脉造影专用导管,1967年，Melvin P. Judkins设计冠脉造影专,6,1977,Gruentzig, performs,first cath lab PTCA,on awake patient in Zurich; starting with this case,all PTCA data is entered into a worldwide registry,1977 Gruentzig, performs fi,7,输送各种介入器械,支持作用,注射造影剂及各种相关治疗、抢救药物,血流动力学监测,导引导管功能,输送各种介入器械导引导管功能,8,导引导管选择要求,创伤小,同轴性好,支撑力好,足够管腔直径,导引导管选择要求 创伤小,9,柔软的,可视头端,（安全区）,柔软的,同轴段,（柔软区或传送区）,中等硬度的,抗折段,（支撑区）,牢固的,扭控段,（扭控区或推送区）,导引导管节段,柔软的可视头端（安全区）导引导管节段,10,导引导管构造,外 层 ,聚乙烯塑料,决定导管形状、硬度和与血管内膜间的摩擦力,中 层 ,12-16根钢丝,编织成，使导管具备抗折断、抗扭曲、,顺应性和弹性（不同厂家编织方式不同）,内 层 ,尼龙聚四氟乙烯（PTFE）涂层,，减少导丝、球囊、,支架与导管内腔间摩擦力，抗血栓,导引导管构造,11,支撑力,内径大小,顺应性,扭控性,抗折性,导引导管性能参数,钙化,迂曲,闭塞,支撑力导引导管性能参数钙化迂曲闭塞,12,导引导管支撑力,被动支撑,（通过导管结构和外形获得支持）,主动支撑,（术者操作获得）,导引导管支撑力 被动支撑 （通过导管结构和外形获得支持）,13,被动支撑力,取决于,直径,、,结构,、导管与主动脉壁,接触面积,和,夹角,。,1、直径,越大,、支持力越强。,被动支撑力 取决于直径、结构、导管与主动脉壁接触面积和夹角。,14,2、中层钢丝,编织方式,。,一圆一扁,钢丝编织成的相对较硬、支持力强；,扁平钢丝,编织成的导管柔软、支持力弱。,Cordis Vista,Medtronic Launcher,2、中层钢丝编织方式。Cordis VistaMedtron,15,Boston Mach 1,2 X 2编织:,2根圆钢丝在另2根圆钢丝之上,Boston Runway,4 X 2编织:,抗折性、扭控性更好,Boston Mach 1 2 X 2编织:Boston R,16,3、导管与主动脉内壁接触面积,越大,，支持力越强。,JL4.0,SL4.0,EBU3.75,3、导管与主动脉内壁接触面积越大，支持力越强。 JL4.0S,17,4、导管与主动脉,夹角,越接近90度，支持力越强，夹角越小，越差。,4、导管与主动脉夹角,18,主动支撑力,Deep seating使其与主动脉夹角更趋于90度,JL4.0,主动支撑力Deep seating使其与主动脉夹角更趋于90,19,Downsizing from (6F) to (5F) after rotational atherectomy via tranradial approach with,safe deep cannulation,may be a solution to,compass lacks of support,and to lead to cross the calcified lesions and deployment of the stent.,Deep seating,Cardiovascular Resvacularization Medicine, 2011,Downsizing from (6F) to (5F) a,20,1.5 mm bur,6F EBU,1.5 mm bur6F EBU,21,Deep seating,5F EBU,Deep seating5F EBU,22,深插方法,（避免开口部损伤）,深插方法（避免开口部损伤）,23,内径大小,内径大小,24,Medtronic,Launcher,大腔导管,Terumo,Full Wall技术,Medtronic大腔导管TerumoFull Wall技术,25,指导管在体内被旋转、操控的能力。,决定于钢丝编织方式和polymer特性。,扭控力、抗折力,指导管在体内被旋转、操控的能力。扭控力、抗折力,26,导引导管类型,导引导管类型,27,Judkins导管,（操作简单，适用于简单、中等难度病变）,常用导引导管,点状被动支撑,不与动脉壁接触,源于导管本身结构,Judkins导管（操作简单，适用于简单、中等难度病变）常用,28,Judkins导管型号,Judkins导管型号,29,短头导管,正常,短头导管正常,30,短头导管,正常,短头导管正常,31,XB 3.5,支撑力较JL增加67%,Cordis Vista Brite Tip,Extra Backup类导引导管,JL基础上改进,头端直线形，更好同轴,第二弯曲与左冠开口对侧主动脉壁贴合更长,选择XB应比JL小0.5,XB 3.5支撑力较JL增加67%Cordis Vista,32,XB LAD,XB C,支撑力较JL增加50%,形状介于XB,和XBLAD之间,操作方便,XB LADXB C支撑力较JL增加50% 形状介于XB,33,弧度较大的第二弯曲紧靠,对侧主动脉壁。,Medtronic EBU,弧度较大的第二弯曲紧靠Medtronic EBU,34,Boston left specialty curves,LAD,通常选Q curve 4,通常选Voda 3.5,支撑力更好,Boston left specialty curvesLA,35,XBRCA,ART,MAC,(Multi Aortic Curve),对侧壁提供后座力,支持力介于JR和,Amplatz之间,与BSC的,ART,或MDT,的,MAC,相似,XBRCAARTMAC (Multi Aortic Curv,36,头端直线形，通过对侧壁提供额外后座力同时可深插,适合开口向下RCA,与,BSC的Voda Right或MDT的,ECR,相似。,XBR,ECR,头端直线形，通过对侧壁提供额外后座力同时可深插XBRECR,37,指引导管的选择和操作技术课件,38,Medtronic RBU,（Right back up),对侧壁支撑,适合开口平行或,向下RCA,通常插入10-12mm,介于MAC和,Amplatz之间,通常使用RBU3.5,MAC,Medtronic RBU （Right back up)对,39,Amplatz导管,良好的,同轴和被动支持力，可用于,多数起源异常,冠状动脉。,根据L段长短分为AL0.75、AL1、AL1.5、AL2、AL3、AL4,根据R段的长短分为AR1、AR2,Amplatz导管,40,指引导管的选择和操作技术课件,41,第二弯曲与冠状窦及,对侧壁贴合，多点支撑,AL2用于LCA,AL1、0.75用于RCA,AL,第二弯曲与冠状窦及AL,42,AR,第二弯曲小,限制器械通过,支撑力弱,仅用于“牧羊钩”样RCA,AR第二弯曲小,43,进出导管时需注意：,1、当Amplatz导管的“L”或“R”段位于冠状动脉,开口水平线上方,时，可,直接撤出或深插导管,。,进出导管时需注意：,44,2、当“L”或“R”段位于冠状动脉,开口水平线下方,时，切,忌直接后撤导管,，,应推送导管，以底部为支撑点，使导管尖端后退，,离开冠脉开口，,再旋转导管,。,推送,旋转,2、当“L”或“R”段位于冠状动脉开口水平线下方时，切忌直接,45,短头Amplatz导管,标准,短头,刮伤主动脉窦情况,大大降低，造成靶血,管撕裂、 夹层可能降,到最低,入冠不深，几乎没有,嵌顿现象、,短头Amplatz导管标准短头 刮伤主动脉窦情况,46,其他导引导管,主要适用于向下的冠脉开口，可用于LCA和RCA。,MP,其他导引导管 主要适用于向下的冠脉开口，可用于LCA和,47,向上开口,RCA 和桥血管,支撑力介于JR和Amplatz之间,第一个,弯较直,，便于输送器械,HSII,用于正常直径主动脉,HSI 用于窄主动脉,HSIII 用于宽主动脉,向上开口 RCA 和桥血管,48,Medtronic,主要用于开口向上血管,Medtronic主要用于开口向上血管,49,导引导管选择,同轴,导引导管选择同轴,50,同轴不良引起冠脉开口损伤,同轴不良引起冠脉开口损伤,51,指引导管的选择和操作技术课件,52,型号选择,开口高，选小号,开口低，选大号,型号选择开口高，选小号,53,LCA导引导管选择,JL4,开口高或主动脉根部小，可用JL3.5,LM短，用短头,扭曲、钙化、闭塞用Amplatz或Extra backup,LCA导引导管选择 JL4,54,RCA导引导管选择,JR4,开口向上，用Amplatz或Hockey stick,RCA导引导管选择 JR4,55,JL 3.5,开口向上或水平,JL 3.5开口向上或水平,56,冠脉起源异常导管选择,左冠口起源于右冠窦，选JR4或Amplatz,右冠起源于左冠窦，选Amplatz或JL,升主动脉造影,或,CTA,有帮助,LCA起源右冠窦,冠脉起源异常导管选择 左冠口起源于右冠窦，选JR4或Ampl,57,三维导管在,不同轴向上,进行各种弯曲、形状的设计如3DRC,(Mdetronic),导管。,三维导管在不同轴向上进行各种弯曲、形状的设计如3DR,58,Sherpa NX Active 3DRCA,螺旋状尾端,第2、3弯顶在主动脉壁提供强支撑,0.032inch导丝引导进入后顺时针或逆时针旋转,Sherpa NX Active 3DRCA 螺旋状尾端,59,AP-Cranial见RCA起源于左窦,AP-Cranial见RCA起源于左窦,60,LAO见RCA起源异常,LAO见RCA起源异常,61,桥血管导引导管选择,静脉桥血管导管选择,常凭经验,CTA,或,升主动脉造影,有帮助,桥血管导引导管选择 静脉桥血管导管选择常凭经验,62,LCB,(Left coronary bypass),/,RCB,(Right coronary bypass),导引导管,LCB (Left coronary bypass),63,右冠桥血管,右冠桥血管多起源于主动脉根部上方2-3cm的前壁，开口多向下，选择MP、Amplatz或RCB。,右冠桥血管 右冠桥血管多起源于主动脉根部上方2-,64,左冠桥血管,前降支和回旋支桥血管开口起源于右冠桥上侧方，选择JR、LCB、Hockey Stick、Amplatz或MP。,左冠桥血管 前降支和回旋支桥血管开口起源于右冠桥上,65,开口如无明显成角，用JR4或LCB,明显成角者用专用导管（IMA),可选择,左侧桡动脉入路,LIMA桥血管,IMA,开口如无明显成角，用JR4或LCBLIMA桥血管IMA,66,LCB IMA JR,LCB IMA JR,67,需要更大支持力怎么办,？,更大直径,深插,（头端较直、较细导管更易深插，且可减少对冠脉损伤）,子母导管,需要更大支持力怎么办？ 更大直径,68,Heartrail II (,Terumo, Japan,),long,(120 cm),5 Fr catheter,(13 cm very soft end portion),Absence of curve,and the,flexibility of its tip,permit the,“child” catheter coaxial with the target vessel, minimizing,the risk of dissection.,5 in 6,guiding catheter technique,Inner catheter,Heartrail II (Terumo, Japan)5,69,Filled with water that was kept at 37C,5 mm/s,Filled with water that was kep,70,Switching to 5-in-6 system,Switching to 5-in-6 system,71,Coronary artery injury,Deep-vessel engagement can be,facilitated by passage of a balloon catheter,Air embolism,Coronary artery injury,72,7F AL-1; 3.5mm balloon,7F AL-1; 3.5mm balloon,73,指引导管的选择和操作技术课件,74,(Goodman, Japan),(Goodman, Japan),75,The lumen size of the aspiration catheter as the size of SES is limited to,3.0 mm,.,The lumen size of the as,76,GuideLiner cath,Rapid exchange,Flexible yellow,20 cm,straight extension connected to,a stainless-steel push tube,Results in an I.D. approximately 1F size smaller,available in three sizes: 6F, 7F and 8F,GuideLiner cath Rapid exchang,77,指引导管的选择和操作技术课件,78,指引导管的选择和操作技术课件,79,指引导管的选择和操作技术课件,80,Not recommend,its use in target vessels of 7F GC,5-in-6 system,85,4-in-6 system,Extending 5 cm, the backup support signicantly increased,but still 7F GC,4-in-6 system,86,Trackability of GC,Using balloon-anchoring technique,5F child catheter could be advanced to,13.0 cm, whereas the 4F child catheter could be advanced to,15.0 cm,(,P90% success rate for,51 lesions,in which conventional techniques had failed.,Success may be contributed, in most part, by the,trackability of the 4F child catheter,.,Does not usually compromise the coronary flow.,Provided 90% success rate for,88,Peripheral balloon anchor method,Balloon used for predilatation to the,most distal portion of the lesion,.,Inated and used as the,anchor,KIWAMI is,inserted slowly,toward inated anchoring balloon.,Not to dilate,the balloon at the healthy portion,Peripheral balloon anchor meth,89,Cypher (3.0, 18 mm),Cypher (3.0 18 mm),90,5-Fr ST01 allows,any BMS and DES,KIWAMI effective for stents with a diameter up to,3.0 mm,for,Cypher,and,TAXUS,Liberte,3.5 mm,for,Endeavor,Most of BMS,can be deployed using KIWAMI except DRIVER (Medtronic),5-Fr ST01 allows any BMS and,91,经桡动脉,PCI,导引导管选择,和经股动脉基本原则一致,右侧桡动脉导管型号比股动脉小半号，,左侧和股动脉相同,经桡动脉PCI导引导管选择 和经股动脉基本原则一致,92,Comparing the backup force between TFI and TRI,it was found to be,60% greater,in TFI with a,JL,catheter, and,8% greater,in TFI with a,backup,(EBU/XB),type catheter.,J Invasive Cardiol. 2005 Dec;17(12):636-41,Comparing the backup force bet,93,the Ikari L (IL) catheter generated a,similar,backup force,between TRI and TFI.,特有的第1弯曲利用右锁骨下动脉和无名动脉间夹角提供强支撑力,J Invasive Cardiol. 2005 Dec;17(12):636-41,经桡动脉,PCI,专用导引导管,the Ikari L (IL) catheter gene,94,JL,IL,JR,IR,JLILJRIR,95,Fajadet导管,JFL,JFR,(France),Long tip设计提供良好支撑力和同轴性。,Fajadet导管JFLJFR(France)Long ti,96,MUTA-L/R,MUTA L导管和JL导管相似，但支撑力比后者强，MUTA R导管弯曲是一种三维设计，有MR2和MR3两种，MR2最常使用。,MUTA-L/R MUTA L导管和JL导管相似，但,97,适合右侧桡动脉入路，可用于左右冠和静脉桥，较Judkins导管同轴性和主、被动支撑力好，易于操控，但较long-tip导管支撑力差。,左右共用导引导管,AMI病变,直接使用节省时间,KIMNY,Curve,适合右侧桡动脉入路，可用于左右冠和静脉桥，较Judki,98,Radial Brachial,(Cordis),3个弯度设计；适于水平或开口向下病变可以深插；左右桡动脉入路均可。,Radial Brachial (Cordis) 3个,99,Radial Runway,适合右侧桡动脉入路，可用于,左右冠和静脉桥,，结构特点类似与KIMNY。,分为标准、短头和高位开口头。,Radial Runway 适合右侧桡动脉入路，可用于左,100,Barbeau导管,Barbeau导管,101,Male（mm）,Female（mm）,国外,3.10.6,2.80.6,魏盟,2.70.4,2.30.4,贾三庆,2.650.60,2.200.49,Radial artery diameter,Male（mm）Female（mm）国外3.10.6 2.,102,radial artery internal,diameter /,sheath external,diameter,4%,in patients with ratio,1,13%,in patients with ratio,1,The,dosage of heparin, the,diameter of radial artery,and,the post-procedure,compression pressure and time,were,independent risk factors,for RAO,Cathet Cardiovasc Diagn 1997;40:156158,radial artery internal diamete,103,Radial artery diameter,6F sheath external diameter = 2.62mm,Radial artery diameter6F sheat,104,M,M,ain prox. first,A,Main,A,ccross side first,D,D,istal first,S,S,ide branch first,Extended V,Skirt,PM,stenting,MB stenting,across SB,MB stenting,+ kissing,MB stenting,+ SB balloon,Elective,T stenting,Internal,crush,Culotte,TAP,DM,stenting,Provisional,SKS,V,stenting,SKS,Trouser legs,and seat,SB ostial stenting,SB,minicrush,SB crush,Syst. T Stenting,Minicrush,Crush,After,balloon,2 stents,3 stents,1,st,stent,Skirt + DM,Skirt + SB,Strategy selection (6F),MADS classification Y. Louvard, CCVI pending,MADSExtended VSkirtPM MB stent,105,Guiding catheter selection,Large inner diameter,Launcher (Medtronic) and Heartrail II (Terumo),Good back-up support,LCA: EBU, BL, XB, Voda, Q-curve, Ikari L,RCA: AL-0.75/1,AR-1/2,JR,JL3.5, XBRCA,Guiding catheter selection,106,Radial artery diameter,5F sheath external diameter = 2.29mm,Radial artery diameter5F sheat,107,0.010-inch guidewire and compatible balloon catheter,IKAZUCHI-X,(KANEKA Medix Corporation Osaka, Japan),Double,balloon ination with a,5-Fr,guiding catheter,Triple,balloon ination with a,6-Fr,guiding catheter,6F,0.010-inch guidewire and compa,108,Comparison of profile among balloon catheter systems,Comparison of profile among ba,109,Coil-type guidewires:,Athlete Slender 01,(Japan Life Line, Tokyo, Japan),Decillion FL, and Decillion MD,(Asahi intecc, Nagoya, Japan),Hydrocoated guidewire：,the Athlete Eel Slender,(JapanLife Line, Tokyo, Japan),IKAZUCHI-X,Semi-compliant balloon,Diameters from 1.5 to 3.5 mm,Length is 9 mm for a 1.5 mm diameter and 15 mm for other diameters,Nominal pressure is,8 atm, rated burst pressure is,14 atm,.,Coil-type guidewires:,110,Radial artery diameter,The frequency of this ratio ( 1.0) for,7,and,8 Fr,sheaths was,71.5%,and,44.9%,in male patients and,40.3%,and,24.0%,in female patients.,Radial artery diameterThe freq,111,7F sheath and guiding catheter,7F sheath and guiding catheter,112,指引导管的选择和操作技术课件,113,指引导管的选择和操作技术课件,114,Sheathless GC system,(Asahi Intecc, Japan),hydrophilic GC + central dilator.,Sheathless GC system (Asahi I,115,The outer diameter of the,6.5 F sheathless GC,(2.16 mm),is smaller than a,5 F sheath,(2.29 mm).,The outer diameter of the,7.5 F sheathless,GC,(2.49 mm),is less than that of a,6 F sheath,(2.62 mm).,Thicker,than conventional guide catheters due to,an,addition layer of steel braiding,and the hydrophilic coating,aids backup support.,The outer diameter of the 6.5,116,After the diagnostic angiography, the sheath was exchanged for the sheathless catheter,over a standard 150 cm J-tipped 0.035-inch,(Terumo, Japan),wire,.,After the diagnostic angiograp,117,指引导管的选择和操作技术课件,118,Sheathless GCs,slide easily,within vessels due to the,hydrophilic coating, disengagement of the catheter could happen in cases requiring good guiding support.,Tegaderm adhesive dressing,Sheathless GCs slide easily w,119,Disadvantage,The,shapes,of catheters were slightly diferent from those,of conventional catheters.,This system,requires more,time,to assemble,Extra care,should be exercised when coronary intubation,is attempted to prevent catheter tip induced coronary,artery,dissection,.,Disadvantage,120,指引导管的选择和操作技术课件,121,指引导管的选择和操作技术课件,122,Performed PCI in,100 consecutive cases,using 6.5 Fr sheathless guides,Radial occlusion rate of,2%,using 6.5 Fr catheters,0%,with 4 Fr systems and,17%,with 5 Fr systems,611%,with 6 Fr guide catheters.,Radial spasm rate of,5%,using 6.5 Fr catheters,1.1%,with,5 Fr systems,22%,using 6 Fr Sheaths.,UK,Performed PCI in 100 consecuti,123,Severe artery spasm: making manipulation difficult,Upper limb artery spasm,High origin of radial artery,Accessory brachial artery,Severe artery spasm: making ma,124,指引导管的选择和操作技术课件,125,指引导管的选择和操作技术课件,126,The conventional GC did not pass through bifurcation high origin radial artery.,6.5 Fr sheathLess GC,passed through,The conventional GC did not pa,127,“Pseudo-taper”,Guide catheters inserted with a long (125 cm) 5 or 6 Fr Inniti Diagnostic Catheter,(Cordis Corporation, Miami, FL),over a 0.035 inch J-tip guidewire,USA,“Pseudo-taper” USA,128,Catheterization and Cardiovascular Interventions 76:911916 (2010),Catheterization and Cardiovasc,129,导引导管手工塑型,“钓鱼”技术,先,送入导丝甚至球囊或微导管，,再,送入导引导管,导引导管手工塑型“钓鱼”技术先送入导丝甚至球囊或微导管，再送,130,指引导管的选择和操作技术课件,131,8F AL 1,guiding catheter (arrow),5F multipurpose inner catheter,(arrow head),coaxial double catheter,8F AL 1 guiding catheter (arro,132,300 cm-long BMW,Buddy wire,300 cm-long BMW,133,指引导管的选择和操作技术课件,134,指引导管的选择和操作技术课件,135,Thanks !,Thanks !,136,