1、经桡动脉入路经桡动脉入路行全脑血管造影行全脑血管造影1 1989年加拿大医生Campeau 首先报道应用桡动脉穿刺进行冠状动脉造影取得成功，在心血管介入诊疗中逐渐发展 。 优点：表浅，止血容易，并发症少； 无需长时间卧床，缩短留院时间，节省费用； 患者易接受 桡动脉穿刺技巧和血管动脉造影技术。2 适应症（Indications）(a) 随诊（imaging follow-up） ; (b) 门诊患者（cerebral angiography on an out-patient basis）;(c)较差的股动脉入路 （ poor femoral access）; (d) 应用抗血小板或抗凝治疗患
2、者（patients on antiplatelets or anticoagulation therapy）3 禁忌症桡尺动脉侧支循环不良Allen试验 5秒其它：桡动脉难触及；身材矮小女性桡动脉较细；头臂干或锁骨下动脉严重疾病；穿刺部位严重瘢痕等4 桡动脉血氧监测The arterial waveform and arterial O2 saturation (SaO2) were checked via a pulse oximeter applied to the thumb. 5 桡动脉穿刺技术6 桡动脉解剖定位7 桡动脉穿刺和置入动脉鞘操作难点较细小，易痉挛，不易穿刺成功 ；周围支
3、撑组织少，有高血压和动脉样硬化时易滑动；有分支和走向解剖变异。8 穿刺前仔细扪诊桡动脉了解其走向、血管弹性、搏动情况 Allen试验或桡动脉血氧监测开始注射麻药不宜过多，0.3-0.5ml皮下浸润 ；专用的桡动脉穿刺针：Cordis公司的空心钢针和Terumo公司的套管钢针 21-G穿刺成功后退针应缓慢；导丝和动脉鞘管进入时应无阻力，若稍有阻力，则应在透视下操作切忌粗暴推送 。 9 穿刺点选择桡动脉 过于靠近远端，误入分支血管； 过于靠近近心端，增加穿刺的难度 穿刺失败，向近心端移重新选择穿刺点。 穿刺点一般在桡骨茎突近端1cm处：走行较直、相对表浅，穿刺容易成功，分支相对较少，穿刺误入分支血
4、管的几率较小。但在少数桡动脉迂曲、变异，穿刺点的选择应因人而异。理想的穿刺点应选择在桡动脉走行较直且搏动明显的部位。10 局麻建议应用“两步法”给予局麻药物，即穿刺前皮下少量注射麻药，穿刺成功后在鞘管置入前再补充一定剂量的麻醉药物。但在注射麻醉药物时进针不宜过深，以免误伤桡动脉。 11 穿刺技巧“The first is the best ”腕部垫高，腕关节处于过伸状态穿刺者左手指轻放于患者桡动脉搏动最强处，指示患者桡动脉的走行方向。避免按压过度，会造成桡动脉远端的血流受阻，人为增加了穿刺的难度。进针角度一般3045，但对于血管较粗或较硬者，进针角度应稍大；而对于血管较细者进针角度应略小；针尾
5、部见回血，再前送穿刺针少许后，套管针穿刺者，应先退出针芯后再回撤套管，注意退出针芯时确保固定套管位置，至针尾部喷血后再送入导丝，不能有阻力。如进针后未见针尾部回血，可用左手食指判断此时穿刺针与桡动脉的位置关系，再回撤穿刺针至皮下，调整针尖方向后再次进针。12 送入导丝穿刺针尾端喷血良好，固定针柄以确保穿刺针位置不动，同时右手送入导丝，动作应轻柔遇到阻力应停止前送导丝，可部分回撤导丝后，改变穿刺针的角度或旋转穿刺针调整导丝的前进方向后再次试送导丝，切忌强行推送导丝，误伤小分支导致前臂血肿的发生。通常情况下要求前送导丝至少应达到尺骨鹰嘴水平后再沿送鞘管。13 置入鞘管置入鞘管前，需在穿刺部位补充麻
6、醉药。动脉鞘管表面附有亲水涂层材料，降低鞘管送入时的摩擦力，防止桡动脉痉挛发生。 置入鞘管后一同撤出扩张管及导丝。如能经侧管顺利回血，可判定鞘管位于血管真腔，桡动脉穿刺成功。A 5-F introducer sheath was inserted into the radial artery. 14 注意动脉鞘连接生理盐水过多的冲洗，会导致动脉痉挛，应避免。肝素20003000IU。若出现痉挛，可注入硝酸甘油（150250ug）或维拉帕米（ 150250ug）。 15 桡动脉穿刺过程桡动脉穿刺过程中常见的问题及处理中常见的问题及处理同一部位反复穿刺不成功穿刺针刺入桡动脉，但穿刺针尾部血流不畅穿
7、刺针回血良好，但送入导丝时阻力较大置入鞘管时阻力较大 16 穿刺不成功未能刺中桡动脉：针对不同情况改变穿刺手法后进针。 例如：较硬易于滚动的桡动脉，搏动很强，但难以刺中 选择裸针穿刺更具优势，加大进针角度和速度 ； 桡动脉较细、搏动较弱 选择套管针穿刺进入真腔的成功率高，小角度穿刺，缓慢进针 。桡动脉走行迂曲：更换穿刺点至走行较直部位后再行穿刺；桡动脉发生痉挛：桡动脉的搏动减弱甚至消失。盲目穿刺可能会进一步加重桡动脉痉挛，等桡动脉搏动恢复后再行穿刺；（应用解痉药） 穿刺局部形成血肿：应避开血肿部位后重新选择穿刺点。17 穿刺针尾血流不畅穿刺针尾血流不畅或送入导丝阻力较大或送入导丝阻力较大针尖斜
8、面未完全进入血管腔：针尖的位置可能位于前壁或后壁调整穿刺针的深度和进针角度使针尖完全进入血管腔。桡动脉痉挛不喷血，但导丝常可顺利前送，不会对桡动脉入路的建立带来太大的障碍。进入分支：调整穿刺针位置后仍无法顺利前送导丝常提示此种可能，穿刺点过于靠近腕部时多见，常需要向近心端前移穿刺部位后再次进针。桡动脉迂曲：透视下调整导丝的前进方向后再试行通过弯曲段血管，必要时可能需要更换穿刺部位。18 共有并发症共有并发症穿刺部位出血、血肿及假性动脉瘤 动静脉瘘 动脉夹层、动脉血栓、闭塞和穿刺动脉远端栓塞 19 桡动脉途径相关独有并发症桡动脉途径相关独有并发症桡动脉 特点：超声测定直径:平均2.600.41
9、mm, 82%病人适合5F鞘管。 注意：老龄、高血压患者桡动脉迂曲，无名动脉与主动脉弓成锐角；0.4%2%右锁骨下动脉起源升主动脉远端或水平型主动脉弓后方。约7%9%病人不适宜桡动脉操作，强行操作会增加桡动脉特有并发症的发生。20 独有并发症独有并发症桡动脉痉挛：平滑肌受肾上腺受体控制，易痉挛。与紧张、反复穿刺、麻醉不充分、粗暴送入钢丝和导管有关术前充分镇静、提高穿刺成功率、使用硝酸甘油或维拉帕米有效。严重痉挛导致鞘管或导管无法拔出避免强行，应该在病人充分放松后延迟拔。 血肿：桡动脉破裂血肿导致前臂挤压综合征，发生率低，但未及时减压处理，可终身致残。 21 前臂筋膜综合征在肢体骨和筋膜形成的间
10、隔区内，各种原因造成组织压上升，致血管受压，血液循环障碍，肌肉、神经组织严重供血不足，发生缺血坏死，最终导致 些组织功能损害，由此而产生的一系列症候群，统称为筋膜间隔区综合征。通常缺血30分钟，即发生神经功能异常；完全缺血1224小时后，则发生肢体永久功能障碍，出现肌肉挛缩、感觉异常、运动丧失等表现。典型者五“P”症：由疼痛转为无痛（Painless）;苍白（Pallor）或紫绀，大理石花纹等;感觉异常（Paresthesia）；肌肉瘫痪（Paralysis），无脉（Pulselessness）。 预防方法：避免反复多次透壁穿刺，尽量小鞘管，导引钢丝永远至于导管的前方，轻柔操作。22 前臂水肿
11、长时间过度压迫导致静脉回流不畅，尤其在合并前臂血肿时更易出现。一般2小时应该明显松解压迫，避免大面积的压迫桡动脉周围。 23 拔鞘拔鞘后局部压一小沙布球，弹力绷带包扎：松紧适度，手腕制动6小时。观察末梢血供情况（颜色、温度）及患者感受，可每2小时松解一次。24 Loop formation at the radial artery in a 75-year-old man interfered with insertion of the guide wire of the introducer sheath25 During guide wire insertion through the r
12、adial artery, it entered the radial recurrent artery返动脉, causing sharp pain in the forearm. 26 Thrombus migrating into the ulnar artery during DSA of the forearm artery performed at the end of the examination.27 Ultrasonic assessment of vascular complications incoronary angiography and angioplasty a
13、fter transradial approach.Am J Cardiol 1999;83:180 186. Nagai et al. and Yokoyama et al.have reported three factors related to radial artery occlusion:the diameter of the radial artery prior to the procedure；the ratio of the radial artery diameter to the sheath outer diameter；diabetes.28 Limitations
14、 of Successive Transradial Approach in the Same Arm: The Japanese ExperienceCatheterization and Cardiovascular Interventions 54:204208 (2001)812 patients TRA was successfully performed three times in 90% of the men and 80% of the women.In conclusion, TRA in the same arm can be performed three to fiv
15、e times in most Japanese patients.29 全脑血管造影30 主动脉弓造影猪尾导管置于升主动脉内31 Simmons导管使用法Simmons导管有三型，即I、型(图)。 32 有较长的、开袢状的两个弧与两个臂。I型的远侧臂长3.6cm，型远侧臂为6.4cm，型为8.4cm。根据主动脉弓的直径决定导管远侧臂的长度应至少比要插管的血管水平处主动脉的宽度稍长，当注射造影剂时导管才不会弹出血管。主动脉弓成袢方法：2种 33 成袢方法2种：降主动脉成袢：较安全升主动脉成袢：用于迂曲、扩张的主动脉弓，导丝不能到达降主动脉时 34 A method of folding the
16、 Simmons catheter curve using the aortic arch by the looping method (Method 1). (a) The tip of the catheter is negotiated into the descending thoracic aorta with the aid of the distal curve of the catheter and a J-tipped guide wire. (b) The main loop is formed by pushing the catheter into the ascend
17、ing aortic arch while the guide wire is within the catheter with the tip at the primary curve of the catheter. (c) Now the curve is formed within the ascending aorta ready to select the supra-aortic branches. 35 A method within the ascending aorta (Method 2). With very tortuous and wide aortic arch,
18、 Method 1 cannot be utilized because advancing the guide wire to the descending thoracic aorta is impossible. (a) A guide wire loop is made within the ascending aorta with the top of the loop abutting the cusps of the aortic valve. (b) A catheter is then advanced over the loop of the guide wire. The
19、 course of the catheter and wire is blurred due to the cardiac motion. (c) Finally the catheter curve is obtained. 36 (a) L-SUB-VA(b) L-CCA(c) L-ICA( with acute branching pattern use of a stiff guide ) (d) R-CCA(e) R-SUB-VA 37 A. A 0.035-inch guide wire was passed though the radial and brachial arte
20、ries. B. A guide wire and a 5-F Simon II catheter were introduced into the ascending aorta. C. The guide wire was turned back at the aortic valve. D. A J-curve was made at the distal portion of the Simon II catheter 38 When handling the catheter, the brain supplying arteries can be easily selected.
21、A. L-CCAB. L-ICAC. R-CCAD. L-VA39 A. During catheter handling to select the R-CCA, the catheter kinked because of excessive torque. The innominate artery was very tortuous in this patient. B. The catheter was withdrawn. Focal kinking is demonstrated in the catheter.40 SimmonsIII导管造影41 注意操作导管在透视下进行：进
22、管、超选血管及撤管时；导丝辅助 Simmons导管独特的头端弯曲，应注意避免损伤血管壁一般应用导丝引导进入血管；难点：L-ICA,L-VA（角度）；经验：一般应用 5F Simmons 导管 较易操作，不易纽结，尤其是血管迂曲者； 导管到达降主动脉困难应用猪尾导管长交换导丝至降主动脉，再将Simmons导管交换到位，可用方法1成袢。 少数可直接进入右侧颈总动脉内成袢42 Transradial Approach for Diagnostic Selective Cerebral Angiography: Results of a Consecutive Series of 166 Cases.
23、 AJNR Am J Neuroradiol 22:704708, April 200143 The radial artery was successfully punctured and cannulated in 154/ 166 patients. Selective catheterization of the intended vessels was obtained in all carotid and vertebral angiographic procedures with no major vascular complications.CONCLUSION: Compar
24、ed with transfemoral and transbrachial approaches, the transradial approach is a less invasive and safer technique for selective cerebral angiography and may warrant consideration as a standard procedure. Anticoagulant or antiplatelet therapy need not be discontinued for this method.44 Transradial C
25、erebral Angiography: Technique and Outcomes AJNR Am J Neuroradiol 24:12471250, June/July 2003Successful cases：57 of 60 cases.Sheaths ： 4F to 6F. Mean procedural time for diagnostic cases was 40 minutes 19 SD. Access-site complications: one forearm hematoma.45 Routine transradial access for conventio
26、nal cerebral angiography: a single operators experience of its feasibility and safety British Journal of Radiology (2004) 77, 831-838The arterial access was successful in 96.3% . The supra-aortic vessels were catheterized with success rates of 99.2% (127/128)The mean procedure time was 19.3min (rang
27、e 1055 min).The most frequent complication was arm pain which occurred in 37 patients (28.9%). 46 CONCLUSION: Transradial angiography is a useful tool for diagnostic and interventional neuroangiographic procedures. 47 经桡动脉介入治疗病例少国内国内：经桡动脉行颈动脉狭窄支架成形术的疗效分经桡动脉行颈动脉狭窄支架成形术的疗效分析析2005，12，18中国脑血管病杂志国外国外：Neu
28、roendovascular interventions for intracranial posterior circulation disease via the transradial approach: technical case report.Neurosurgery. 2005 Mar;56(3): Access site complications with carotid angioplasty and stenting.Surg Neurol. 2007 Oct;68(4):431-7. Carotid artery stenting via transbrachial a
29、pproachRofo. 2008 Nov;180(11):988-93. Epub 2008 Oct 14. 48 经桡动脉行颈动脉狭窄支架成形术的疗效分经桡动脉行颈动脉狭窄支架成形术的疗效分析析2005，12，18中国脑血管病杂志49 Vascular interventionLocal cerebral thrombolysis. The patient can be anticoagulated immediately after the procedure. Vertebral artery angioplasty or stenting. Patients with signifi
30、cant tortuosity or ectatic（迂曲扩张） changes of the aortic arch and in patients with acute right VA course from the SCA. 50 p 经常不断地学习,你就什么都知道。你知道得越多,你就越有力量p Study Constantly, And You Will Know Everything. The More You Know, The More Powerful You Will Be写在最后感谢聆听不足之处请大家批评指导Please Criticize And Guide The Shortcomings结束语讲师：XXXXXX XX年XX月XX日
