5-冠脉造影术后常规处理.ppt

冠状动脉造影术后处理冠状动脉造影术后处理 北京安贞医院心内科 吴小凡 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 成功的冠状动脉造影检查取决于规范成功的冠状动脉造影检查取决于规范的手术过程和准确的术后处理：的手术过程和准确的术后处理：拔除鞘管拔除鞘管 止血方式止血方式 术后监测术后监测 并发症处理并发症处理 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 拔除鞘管和压迫止血拔除鞘管和压迫止血 拔管时机拔管时机 绝大多数术后即刻拔管绝大多数术后即刻拔管 术中肝素术中肝素5000单位，单位，ACT2mm 病变：病变：穿刺部位无畸形、动脉粥样硬化或钙化穿刺部位无畸形、动脉粥样硬化或钙化 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Perclose 操作步骤操作步骤 1.准备：准备：把生理盐水注入输送鞘管并看到盐水把生理盐水注入输送鞘管并看到盐水 从标记入口流出从标记入口流出 把打结器泡于盐水中把打结器泡于盐水中 清理及消毒手术部位，放进造影导丝，清理及消毒手术部位，放进造影导丝，确保导丝进入血管内足够长确保导丝进入血管内足够长 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 2 置入缝合器置入缝合器 2.1 放放“脚脚”：2.2 推针：推针：Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 2.3 收收“脚脚”：3.打结：打结：Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 4.1 推推“结结”：4.2 止血：止血：Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Perclose AT 缝线预设在鞘管中，无需打结缝线预设在鞘管中，无需打结 拉出缝合器时要确保“结”拉出，必要时可手工拉出，拉出缝合器时要确保“结”拉出，必要时可手工拉出，注意要同时拉住绿线和白线，单拉绿线可致松结，单注意要同时拉住绿线和白线，单拉绿线可致松结，单拉白线可致死结拉白线可致死结 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Perclose 操作要点及难点：操作要点及难点：适用于适用于58F 缝合前需行髂动脉造影，确认穿刺点在股动脉分缝合前需行髂动脉造影，确认穿刺点在股动脉分叉近端叉近端2mm以上，并排除动脉畸形及穿刺部位有以上，并排除动脉畸形及穿刺部位有斑块者斑块者 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 股总动脉 距离分叉大于 2mm 没有病变 合适的穿刺位点合适的穿刺位点 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 穿刺点位于血管分叉内穿刺点位于血管分叉内 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 穿刺口附近有动脉粥样硬化斑块穿刺口附近有动脉粥样硬化斑块 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Perclose 操作要点及难点：操作要点及难点：拉紧轨线拉紧轨线(1号线号线)方向与股动脉走行一致方向与股动脉走行一致 收“脚”前将鞘管略推送入股动脉收“脚”前将鞘管略推送入股动脉 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Perclose 操作要点及难点：操作要点及难点：推结力度适中，过大可能损坏股动脉，过小会致推结力度适中，过大可能损坏股动脉，过小会致缝合失败，以推结器触到股动脉搏动为准缝合失败，以推结器触到股动脉搏动为准 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Angioseal(millennium)Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Angioseal置入条件：置入条件：位置：股总动脉位置：股总动脉 血管大小血管大小：4mm 以上血管以上血管 病变病变：穿刺部位无动脉粥样硬化或钙化：穿刺部位无动脉粥样硬化或钙化 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 6F Angioseal 6F Angioseal 锚在锚在9mm9mm血管内血管内 锚=3.1%血管横截面 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 6F Angioseal 6F Angioseal 锚在锚在6mm6mm血管内血管内 锚=7.0%血管横截面 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Angioseal操作步骤：操作步骤：1.准备 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 2.送鞘送鞘 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 3.1 释放“锚”释放“锚”安全帽与输送鞘咬合安全帽与输送鞘咬合锚”伸锚”伸出出 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 3.2 释放“锚”释放“锚”安全帽锁止安全帽锁止锚”定锚”定位位 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 4.1 闭合穿刺点闭合穿刺点 Clear stop 压缩标记压缩标记 调节杆调节杆 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 4.2 闭合穿刺点闭合穿刺点 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital Angioseal操作要点及难点：操作要点及难点：2种型号，种型号，6F适用于适用于5F、6F鞘管，鞘管，8F适用于适用于7F、8F鞘管鞘管 操作前行髂动脉造影，确保穿刺点位于股动脉，操作前行髂动脉造影，确保穿刺点位于股动脉，且血管直径且血管直径4mm，排除动脉硬化和钙化者，排除动脉硬化和钙化者 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 股总动脉 血管尺寸大于 4mm 没有病变 合适的病人合适的病人 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital RAO 30O LAO 30O 低位穿刺”低位穿刺”动脉穿刺点靠近血管分叉动脉穿刺点靠近血管分叉部部 Routine management after coronary angiographyRoutine management after coronary angiography Beijing Anzhen Hospital 血管直径血管直径 4mm Routine