血管疾病培训-提供01美国cet viva laird china access

1、Access Site Selection:Basic Anatomy and Angiographic TechniquesJohn R. LairdDirector of the Vascular CenterUniversity of California, Davis Medical CenterSacramento, CAChallenging Access72 year old female:Unstable angina and CHFSevere peripheral arterial disease with bilateral claudication absent rig

2、ht femoral pulse, weak left femoral pulseKnown bilateral subclavian artery occlusionsPotential DifficultiesHuge body habitusSubcutaneous scarringVascular calcificationAtherosclerotic obstructionTortuosityAneurysmal changesBypass-GraftsQuestions to Ask Before You StartWhat access sites are possible?T

3、arget vessel sizeEase of approachBleeding riskPatient comfortRadiation exposureVascular AccessCoronaryRetrograde femoralBrachialCutdownPercutaneousRadialPeripheral Retrograde femoralAntegrade femoralTranspoplitealAxillaryBrachialRadialBypass GraftTibial/pedalFemoral AnatomyExample: How a poor punctu

4、re may easily occur(Potential for a low puncture site prevented with fluoroscopy)G. AnselVascular AccessImportant Equipment:Micro puncture kitSMART needleUltrasoundGuidewiresSheaths (long, crossover)Wire Choices for AccessCoronary hybrid (transition) wireTAD, Jindo.018 tip on .035 wireGenerally not

5、stiff enough to dissect unless forcedMicro-puncture technique.035 torque wire (Wholey, Magic Torque, Storq, SupraCore).035 stiff wire (Amplatz) for fibrous accessInfrainguinal InterventionContralateral Approach vs. Antegrade Femoral PunctureContralateral Approach PreferredVery obese patientOstial or

6、 proximal SFA lesionIntervention performed during same procedure as diagnostic studyIliac intervention performed during same procedureContralateral ApproachPigtail, IMA, Hook, or Cobra catheter to gain access to contralateral iliacAdvance over steerable wire into external mon femoral artery Contrala

7、teral ApproachStiff guidewire to provide support for advancement of crossover sheath or guiding catheterConsider antegrade approach if resistance is encounteredIliac Crossover SheathIliac Crossover SheathSheathsFlexible, kink resistant, long sheath for crossover procedures (Cook, Arrow, Cordis, Teru

8、mo)6 Fr sheath will accept most self-expanding stents90 cm sheath for carotid and subclavian procedures (Cook - Shuttle)Flexible short sheath to prevent kinking following antegrade punctureTechnical ConsiderationsAntegrade Approach Preferred:Lesion in distal infrapopliteal vesselsCalcified or tortuo

9、us iliac system precludes contralateral approachDifficult aortoiliac bifurcation or prior aortofemoral bypass graftDirectional or rotational atherectomy plannedCritical Limb IschemiaPTA of Dorsalis PedisAntegrade Femoral PuncturePoor Antegrade PunctureG. AnselAntegrade PunctureAntegrade PunctureAnte

10、grade PuncturePopliteal ApproachThe “back door” to SFAAnatomyvery deepvein is posterior and slightly lateraltibial nerve is posteriorRiskBleed leads to significant painCompartment syndrome possibleLocating the arteryContrast from aboveUltrasoundTechnical ConsiderationsTranspopliteal Approach Preferr

11、ed:Failure to cross femoropopliteal occlusion from above“Flush” occlusion of SFA (no visible stump)No upper extremity access:Common femoral stenosis (no contralateral access)Stenosis at AFB anastomosisOpen wound or scarred femoral regionTranspopliteal ApproachTechnique:Contralateral access with angi

12、ographic catheter in ipsilateral common femoral Flip patientPuncture popliteal artery under ultrasound guidance or fluoroscopic guidance using with angiographic “road map”HeadPopliteal arteryG. AnselG. AnselFailed antegrade approachG. AnselPopliteal SheathFinal Result Post AngioplastyG. AnselTranspo

13、pliteal ApproachContraindications:Popliteal aneurysmPopliteal artery stenosisSevere obesity or respiratory insufficiency (prevents prolonged use of prone position)Transpopliteal ApproachPotential Complications:Arterio-venous fistulaCompressive hematomaAcute thrombosisAbsent Femoral Pulse?UltrasoundSmart flo