指引导管的选择幻灯片课件

TRI指引导管的选择* 指引导管的结构 常用指引导管的特点 指引导管的选择 原则 组织架构调整原则组织架构设计原则组织架构设置原则财政预算编制原则问卷调查设计原则 特殊情况下的指引导管选择 病例介绍*指引导管的功能为器材输送提供支撑器材和钢丝输送的通道造影剂注射的途径压力监测** 抗折段或支撑段同轴段可视头端或安全段扭控段（推送区）多数指引导管分为四段、三层*各段的主要特性同轴段最优化了头部的柔软性，保证了指引导管操作的柔和性和血管的同轴性抗折段或支撑段吸收了在稍硬段和柔软段之间的扭力，以避免打折扭控段（推送区）硬且柔顺来保证精确的扭力传递，并且，提供稳定的支撑可视头端保证精确的和无创伤性的嵌入，并为测量血管大小提供可靠的参照*指引导管分层 设计 领导形象设计圆作业设计ao工艺污水处理厂设计附属工程施工组织设计清扫机器人结构设计 导管结构分为三层：尼龙外层、中层钢丝、PTFE内涂层最外层　聚乙烯塑料材质，决定导管的形状、硬度和与血管外膜的摩擦力中层　12-16根导丝编织内层PTEF涂层，减少器械和导管内腔的摩擦力*指引导管的重要特征 无创伤性头端 预塑形的弯曲和结构 扭力控制 抗折性 不透辐射性 支撑力 和其他器材的兼容性*最佳的性能大腔润滑 材料 关于××同志的政审材料调查表环保先进个人材料国家普通话测试材料农民专业合作社注销四查四问剖析材料 和其他器材的兼容性内层/涂层不锈钢1:1扭力抗折性外层力量支撑力抗折性柔顺性**Guidecathetersareallconstructedprettymuchthesamewaywithanouterjacketcoveringastainlesssteelbraidandaninnerlumen.指引导管的类型 形态分类：Judkins、XB、Amplatz、Multipurpose、Voda、Qwave 大小分类：5F－8F 结构分类：短头、带侧孔、大腔（ZUMA）*指引导管管径大小的影响 以往必须使用8F导管 目前6-7F导管的内径和以往8F导管的内径相同 当使用管径较小的指引导管时会更多选择“后座力”较好的导管以获得更强的支撑力 管径较大的指引导管往往需要通过侧孔来增加冠状动脉的灌注 ** Historically,an8Fguidecatheter,withitslargelumen,hasbeenneededtodeliverdevicessuchasrotablaters,IVUScathetersandstents.Thishassinceevolvedto6-7Fsizesbecausetheirinternallumensnowmatchthe8Flumens.Thisevolutionwasdrivenbytheconcerntoambulatepatientssoonerandtheincreasein“adhoc”procedures.Smallguidecathetersrequireback-upstylesmorefrequentlyforaddedsupport.Largeguidecathetersrequireside-holesmorefrequentlytoimproveperfusion. 1FR=.013”=.33mm 动脉穿刺点大 易引起压力衰减 造影剂用量大 内腔较小 可视性较差 缺点 更强的被动支撑 更好的可视性 更好的扭力传递 动脉穿刺点小 肱动脉或桡动脉途径 可以主动支撑 造影剂用量少 优点7-8F指引导管6F指引导管指引导管管径大小（F号）的影响*指引导管进展和趋势 造型更适合冠状动脉形状，有更大的支持力（被动支撑）和深插导管操作（主动支撑）新型指引导管XB、XBLAD、XBRCA、XBR、3DRC(codis)、EBU（Medtronic）、QCurve（BostonScientific） 趋向于更小的外径和更大的内腔* 指引导管的结构 常用指引导管的特点 指引导管的选择原则 特殊情况下的指引导管选择 病例介绍*常用指引导管* 公司 系列 LCA RCA 其它 Cordis Vistabritetip JL,JCL,AL,XB,XBLAD,JCB JCB,AR,XBRCA,3DRC,XBR,NR,RCB HS,XBC,MPA Boston Mach1 JL,AL,FCL,CLS,KL,VL,LCB,Q-curve JR,AR,FCR,FR,ART,KB,RCB,VR CLS,HS Medtronic Zuma2,Launcher JL,FLAL JR,FRAR EBU,MAC,Champ,ECR Guidant VikingOptima JL,AL,JCL,GL GR,JCR,SR HS,DL,LIMI,BP-L,MP,CHMP常用指引导管的外形**Thisdisplaysthecurvesofsomeoftheguidecathetersavailableonthemarket.常用指引导管的内腔比较*常用指引导管应用简况1 * 名称 应用 JudkingsleftJL 绝大多数左冠状动脉 FemoralleftFL 绝大多数左冠状动脉 Vodaleft(VL)BSC 导管靠在主动脉壁上，增强支撑力，适合扭曲、成角或闭塞的病变 ExtraBackup(XB)Cordis 导管靠在主动脉壁上，增强支撑力，适合扭曲、成角或闭塞的病变 ExtraBackup(EBU)Medtronic 导管靠在主动脉壁上，增强支撑力，适合扭曲、成角或闭塞的病变 AmplatzLeft(AL) 多用途结构，特别适合高、前壁、成角开口右冠，有难度的左冠、静脉桥 JudkinsRight(JR) 绝大多数右冠和静脉桥 FemoralRightFR 绝大多数右冠 VodaRight 右冠开口成角、近段长、扭曲、开口向上的右冠静脉桥常用指引导管应用简况2 * 名称 应用 AmplatzRight(AR) 开口向下的右冠状动脉或静脉桥 Multipurpose(MP) 开口向下、水平、血管近段长的右冠、搭向左冠的静脉桥 Sones 开口向下、水平、血管近段长的右冠、搭向左冠的静脉桥 Hockey-Stick(HS) 适用于开口向上、水平、血管近段长的右冠 Leftcoronarybapass(LCB) 开口向上的左冠静脉桥 Rightcoronarybapass(RCB) 水平开口的右冠静脉桥 ElGamalbypass(ELG) 可随意成型，适用于开口向上、水平的右冠，左冠静脉桥 Internalmammary(IMA) 内乳动脉专用 Radial（RAD） 桡动脉专用 Castillo（CAS) 类似AmplatzLeftJudkingsleft（JL） JL冠脉导管在头端后有两个特殊的已塑形的弯度 两个弯度之间的距离决定了其导管的形状型号(3.5,4.0,5.0,6.0) JL形状型号的选择取决于升主动脉弓的长度和宽度(比较瘦或升主动脉供窄的人：JL3.5；比较胖或是升主动脉弓扩张的人：JL5.0or6.0)JL4可使用于多数患者 导管技术比较简单：导管头端沿着升主动脉弓边缘推进，直至其滑入左主干开口处（不跨过主动脉弓后不要急剧推进即可）**JR: 第二弯度的长度决定其导管的形状型号JR3.5,4.0,5,0. JR导管由于其头端后直形的导管易于进入升主动脉弓（通常用左前斜位LAO观察）右冠状动脉导管技术: 将导管推送至右冠脉尖端，顺时针方向旋转45°至90°，则头端将被向后拉伸2-3cm. JR头端向前推进2to4cm，在开口上方顺时针方向旋转45°到90°,头端将旋转向下滑入 JR4的头端定位没有血管壁的支撑，因此更需要熟练的操作技巧 尼龙和聚亚安酯的操作感觉不同的JudkingsRight（JR）* 弯度塑形为半圆形，头端与弯度成垂直延伸方向AL导管的形状型号取决于弯度的直径大小(AL1,2,3）多数成人AL2可达到满意的使用效果在LAO位,其头端指向左冠脉开口处AL导管比普通JL导管容易引起血管撕裂的现象发生AmplatzLeft(AL)*AR1，2头端有相似的小的钩形弯度其型号取决于其头端弯度的直径此类导管指向右冠尖端，须顺时针旋转45-90.°AmplatzRight(AR)*直形的导管，近头端有2个侧孔预塑形为一个缓和的钝角MP导管可用于左冠，右冠和左室造影Multipurpose(MP)*IM（内乳动脉）: 有一个特有的钩形头端结构易于进入内乳动脉Internalmammary(IMA)*SonesSones2导管Sones导管可用于左冠和右冠，适合于不同大小的主动脉。操作相对复杂，现不常用*ExtraBackup指引导管应用基础 病变解剖更复杂，靶病变更具挑战性 导管外腔缩小，更需要有足够的被动支撑力 越来越多的病变使用直接支架，要求有更强的支撑力**WhyExtraBackup? 1st-Cordishasaveryniceandcompleteofferingofshapesforextrabackupsupportthathelpthecustomerandcanincreasecompetitivebarriers 2nd-Proceduraltrendscreatemoreneedforbackup *ExtraBackup(XB)Cordis比常用的JL小半号，即JL4=XB3.5支持力比JL大67%有5F,6F,7F,&8F不同的型号2个弯曲，尤其适用于支架术能用于LAD和LCX支架术**XBLAD比常用的JL小半号，即JL4=XBLAD3.5JL4=XBLAD3.5比JL的支撑力强50%易于使器械进入LAD**XBC描述:XBC3.5与Medtronic的EBU4的形状相似。提供了额外的支撑力。它的定位是介于XB和XBLAD之间.插管技巧:将导管沿钢丝向前推进到主动脉根部。轻轻向后提拉导管即可使其进入LCA内。XBC比相应的JL的尺寸小0.5XBC**长病变中应用XBguiding的趋势。与XB和XBLAD的区别在：弧度更贴合血管壁的变化，因此能够适应更多情况下的开口，包括向上，向下等，自我调节性是比较高的Medtronic的EBU和我们的XBC最为接近，所以在扭转EBU时，可先让客户逐渐适应XBC。*XBRXBRCA右冠强支持力导管XBR和XBRCA RCA更强的支持力 从对侧血管壁获得支持力 XBR更易于深插操作，适合于低位RCA**右冠强支撑力导管和JR比较*XBRCA描述:XBRCA通过对侧壁提供了额外的后座力。非常适用于开口向上的RCA。它与BSC的ART或MDT的MAC相似。插管技术:导管沿钢丝向前推进到主动脉根部。导管的头端指向LCA，但位于LCA开口处的下方。缓慢顺时针旋转导管180度，导管则指向了RCA。轻轻向后提拉导管即可使其进入RCA内。**于Amplatz相比，XBRCA的第一个弯相对较为平缓。所以更适用于向上开口病变。EBU是否有用于右冠的XBR描述:XBR通过对侧壁提供了额外的后座力，非常适用于开口向下的RCA。XBR与BSC的VodaRight或MDT的ECR相似。插管技术:导管沿钢丝向前推进到主动脉根部。撤出钢丝使导管恢复本来形状，导管的头端即直接指向RCA。轻轻向后提拉导管即可使其嵌入RCA内。注意在进入RCA时不要扭转。由于可造成主动深插的倾向，不推荐用于主动脉根部狭小的病例。**EBU导管 弧度较大的第二弯曲紧靠对侧主动脉壁，提供出色的后座力**EBU(ExtraBackUp)Catheterusedforleftcoronaryarteries.RBU(RightBackUp)Catheterusedforrightcoronaryarterieswithlateraltoinferiortakeoffs.Broadsecondarycurveallowstheguidetobracefirmlyagainstthecontralateralaorticwallforsuperiorback-upsupport.RequiresminimummaneuveringforsuperbcoaxialengagementoftheLM,LCXorLADbranches.AslightpushforsuperiortakeoffandLADorientation.AslightpullforinferiortakeoffandLCXorientation.DisengagessmoothlyandatraumaticallyintheJudkinstradition.UniqueEBUcurvedesignallowsJudkinsorAmplatzengagementstyles.Easesstentdeploymentbyprovidingavirtuallyfrictionlesspaththroughtheextra-relaxedprimarycurvesegment. 指引导管的结构 常用指引导管介绍 指引导管的选择原则 特殊情况下的指引导管选择 病例介绍* 指引导管要求：同轴性好；支撑力好；冠状动脉内压力好 选择原则：根据冠脉开口解剖特点、升主动脉根部大小、冠状动脉血管大小和部位、病变特点和使用器械*选择指引导管应注意的问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 靶血管开口和走行：开口偏前或偏后，高位或低位，走行向下或向上 是否主动脉增宽或缩窄，决定指引导管第一弯和第二弯的长度 病变严重程度，决定选择导管支撑力 开口是否有病变 是否有需要保护的边支 分叉病变支架术采用的策略 是否使用其它器械，如旋磨或旋切 是否需要深插导管操作*不同冠状动脉指引导管选择 左冠：：多数情况下选择JL4，左主干开口高或主动脉根部小，则选择JL3.5。短左主干选择短头指引导管。对前降支或回旋支扭曲、钙化或完全闭塞病变，需选择强支撑力导管，如Amplatz、Voda、XB或XBLAD、EBU。 右冠：开口水平的RCA，选择JR4即可，开口向上或牧羊钩样，则通常考虑Amplatz、Hockey-Stick*指引导管的选择同轴性调整解剖复杂、复杂病变、血管扭曲，需要超强支撑导管是否超强支撑导管任何同轴性好的导管从对侧主动脉壁获取支撑力从主动脉窦获取支撑力支撑导管**Themostimportantthinginselectingaguideischoosingonethatcangiveyouco-axialalignmentwiththeartery.Thelesionanatomywillhelptodeterminewhatkindofguidecatheterwouldbebestfortreatment.冠脉开口解剖 冠脉开口和主动脉根部连接的位置 右冠开口左冠开口乏氏窦升主动脉 左瓣 右瓣 后瓣主动脉瓣** TheaorticrootiscomprisedoftheSinusofValsalvaandthetubularportionoftheascendingaorta.TheostiaofthecoronaryarteriesarelocatedbehindtheaorticcuspsnearthetopoftheSinusofValsalva.Thecoronaryostialoriginsarethepointsatwhichtheostiumisattachedtotheaorticroot.Deviationsfromthetypicaloriginarehighorigin,bypassgraftorigin,andposteriororanteriororigin.主动脉宽度** Normalaorta:Theaortahasanormalcurvatureanddiameterof3.5cmto4.0cm.Thenormalaorticconfigurationisfoundin60to70percentofallpatients.Narrowaorta:Theaorticarchhasaverytightcurveandasmallerdiameter(lessthan3.5cm).Narrowaorticarchescanmakeadvancingguidingcathetersandinterventionaldevicesmoredifficult.Softguidecatheterscanpartiallycompensateforthetightcurveinthearch.Smallerleftcoronarycathetersareusuallyselectedinthesepatients.Dilatedaorta:Theaorticarchisatamorerelaxedangle.Thediameterisgreaterthan4.0cm.Largerleftandrightcathetersareusuallyselectedinthesepatients.正常主动脉指引导管合适(JL)指引导管合适是指导管的第一弯曲成45o角，并支撑于对侧主动脉壁上** Thesizeoftheaorticrootaffectsthecurvesizeofthecathetertobeused.Theaverageaorticrootgenerallyrequiresa4.0cmcurveguidecatheter,eitheranFL/JLorEBUfortheLCAoranFR/JRfortheRCA.Alargeraorticrootwouldrequirealargercurvedcatheter,suchasanFL/FRorEBU4.5or5.0toprovideadequateback-upsupportfromtheoppositeaorticwall,andenoughlengthtoproperlycannulatetheostium.AnarrowedaorticrootwouldrequireasmallerFL/FRorEBUcurve,suchasa3.0or3.5.Thecurvenotonlyaffectsback-upsupport,butalsodirectstiporientation.Ashorterdistancebetweentheprimaryandsecondarycurveshasatendencytoallowthecathetertomovefartherdownintotheaorticroot,orientingthetipmoresuperiorly,whilealargercurvewillsithigherintherootandtendtoorientthetipmoreinferiorly.Duringthediagnosticprocedure,oneshouldnotehowthediagnosticcathetersitsintheaorta.Thediagnosticcatheteronlyhastositonthelipoftheostiumtoinjectdyevs.theneedforaguidingcathetertoprovidesupport.正常主动脉指引导管不合适(JL)太长**Iftheguidecatheteristoolong,thetipwillassumeaninferiorposition.Theguidewirewillthenfollowtheangleofthecurve(downward)possiblysubselectingtheLCX.正常主动脉指引导管不匹配(JL)太短** Iftheguidecatheteristooshort,thetipwillassumeasuperiorposition.Theguidewirewillthenfollowtheangleofthecurve(transverse/upward)possiblysubselectingtheLAD.冠脉变异1.右冠-正常2.右冠–高位、向前3.右冠–左冠窦、向后4.左冠–正常5.左冠－高位、向前前后21345LAO40ºRSVLSV**Thecoronaryarteryostiumcanvaryinplacementintheascendingaorta.Thisslideshowsthetypesofvariation.Coronaryostiallocation:high,low,anterior,posteriorCoronaryostialorientation:superior,lateral,inferior,shepherd’scrook(RCA’sonly)冠脉起始走向向上向下水平** Lateral:departsatahorizontalangle(90o).Inferior:departsatadownwardangle(45o-60o).Ifchoosingalongercurve,thelongerdistancebetweentheprimaryandsecondarycurveallowsthecathetertositslightlyfartheruptheaorticroot,positioningthetipmoreinferiorly.Superior:departsatanupwardangle(90o-120o).Ifchoosingashortercurve,theshorterdistancebetweentheprimaryandsecondarycurveallowsthecathetertositslightlyfartherdowntheaorticroot,positioningthetipmoresuperiorly.左冠状动脉常见的起始走行水平向下向上**Allowparticipantstoidentifyostialtakeoffsbeforebringinglabelsontoscreen.Angiographicviewsdepictinglateral,inferiorandsuperiorleftcoronaryarterytakeoffs.Pleasenotethattheangiographicprojectionusedcouldaltertheseimages,dependingontheangleofthecamera.AlloftheseappeartobeLAOswiththespineandcatheterinthesameposition.RAOviewsdeterminethetakeoffangleoftheleftcoronarysystem.RAOviewsdeterminecoaxialengagementofthetipintheleftmaincoronaryartery.右冠状动脉的常见起始走行水平向下向上**Allowparticipantstoidentifyostialtakeoffsbeforebringinglabelsontoscreen.Thisslideshowsthecommontakeoffanglesfortherightcoronaryartery.牧羊钩状(仅见于右冠)** TherearetwocommonanatomicvariationsassociatedwiththeRCA,aninferiortakeoffandaShepherd’sCrooktakeoff.AShepherd’sCrooktakeoffiswhenthecoronaryarterydepartstheaortaatanupwardangle,thenmakesasharploopdown.Thecoronaryisshapedlikethetopofashepherd’sstaff.ThemostdifficultofthesevariationsisaShepherd’sCrookwithaveryshortinitialorigin.正常主动脉指引导管的选择*主动脉缩窄或增宽的指引导管选择*冠状动脉开口异常的指引导管选择*异常冠状动脉开口和桥血管的指引导管*内乳动脉和经桡动脉途径的指引导管选择* 指引导管的结构 常用指引导管介绍 指引导管的选择原则 特殊情况下的指引导管选择 病例介绍*桥血管除了左内乳动脉（LIMA）外，其他桥血管均吻合于主动脉前壁** Twotypesofgraftsareusedtobypassthecoronaryarteries:saphenousveingrafts(SVG)andinternalmammaryartery(IMA)grafts,andfreeradialartery.Bypassgraftspresentcannulationdifficultiesbecauseoftheirunusualorientationandlocation.Mostcathetersaredesignedfornativevesselsthatcomeoffoneofthecusps.Thesecathetersaredesignedtocomeovertheaorticarchandorientinaspecificmanner.TheSVGspresentsomeuniqueproblemswhenitcomestoengagement.Thesaphenousveinisremovedfromthelegandattachedproximallytotheaortaanddistallytothecoronaryarterybeyondthelesion.Becauseoftheshortdistancebetweentheaorticarchandtheoriginofthegraft,theguidecathetermustspantheaorta,restingwithitssecondarycurveontheposteriorwallanditstipontheanteriorwalltoprovideastableplatformforadvancingtheballooncatheter.TheIMAarisesfromtheleftsubclavianarteryinproximitytotheheart.TheIMAisdissectedawayfromthechestwall,thedistalendisanastomoseddirectlytothecoronaryarterydistaltothelesionwhiletheproximalendmaintainsitsoriginaltakeofffromthesubclavianartery.桥血管内乳动脉左冠静脉桥右冠静脉桥** Angiographicviewsdepictinginternalmammaryandsaphenousveingrafttakeoffs.静脉桥血管 静脉桥血管导管选择通常是凭经验，很难预料哪种导管适合。升主动脉造影有帮助。 一般而言右冠桥血管选择MP、Amplatz导管或RCB，前降支和回旋支选择JR或LCB、Amplatz、MP *桥血管指引导管右冠状动脉桥血管(RCB)左冠状动脉桥血管(LCB)**内乳动脉内乳动脉开口如果无明显成角，JR4即可到达，如果开口明显成角，则要选择专用的内乳动脉桥血管。**内乳动脉开口如果无明显成角，JR4即可到达，如果开口明显成角，则要选择专用的内乳动脉桥血管。经桡动脉PCI的指引导管常用指引导管XB(XB、XBLAD、XBRCA、XBR)AmplatzJR和JL新型桡动脉指引导管Barbeau型Fajadet型RB(Kimny型)**32*Barbeau经桡动脉指引导管Barbeau**1Fajadet经桡动脉指引导管JFLJFR**Kimny经桡动脉指引导管RBRadialBrachial**经桡动脉指引导管选择的注意事项 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 指引导管选择支撑力好的指引导管：XB、XBLAD、EBU、Amplatz等 指引导管操作轻柔 * 指引导管的结构 常用指引导管介绍 指引导管的选择原则 特殊情况下的指引导管选择 病例介绍*指引导管扭曲**导管扭曲于腋动脉，无法推送、回撤，送入两个硬导丝后撤出。指引导管操作要轻柔，切忌过度旋转、暴力推送导管。头臂动脉迂曲的指引导管选择选择XBLAD或Amplatz等强支撑力指引导管，在导丝引导下操作。*异常起源：LCX起源于右窦主动脉窦造影：LCX起源于右窦AmplatzL1指引导管MP造影导管造影：LCX中段闭塞**急性下壁心肌梗死，左冠造影回旋支缺如。右冠PCI3DRC指引导管*左主干分叉PCI**经桡动脉左主干PCI7FXB3.5指引导管**CYPHERSELECT3.0*33mm到左主干和LAD近段病变处，沿LCX中导丝送CYPHERSELECT2.75*23mm到左主干和LCX近段病变处分叉病变经桡动脉PCI6FXBLAD3.5指引导管**对角支：Firebird3.0*18mm前降支：3.5*33mmFirebird经6F指引导管Kissing扩张CTO病变6FAL1指引导管**6FAL1GUIDINGCATHETERINTERMEDIAT引导导丝在1.5×15mmPLEON球囊支撑下通过病变扩张后置入4.0×15mm的MOTION支架桥血管PCI6FJR3.5指引导管**3.5*32mmTAXUS支架至桥血管近段病变处，支架中段明显凹腰征，残窄30%；送3.0*20mmTAXUS支架无论选择那一种指引导管，术者的经验和操作技巧是最重要的因素！！！***Guidecathetersareallconstructedprettymuchthesamewaywithanouterjacketcoveringastainlesssteelbraidandaninnerlumen.* Historically,an8Fguidecatheter,withitslargelumen,hasbeenneededtodeliverdevicessuchasrotablaters,IVUScathetersandstents.Thishassinceevolvedto6-7Fsizesbecausetheirinternallumensnowmatchthe8Flumens.Thisevolutionwasdrivenbytheconcerntoambulatepatientssoonerandtheincreasein“adhoc”procedures.Smallguidecathetersrequireback-upstylesmorefrequentlyforaddedsupport.Largeguidecathetersrequireside-holesmorefrequentlytoimproveperfusion.*Thisdisplaysthecurvesofsomeoftheguidecathetersavailableonthemarket.**WhyExtraBackup? 1st-Cordishasaveryniceandcompleteofferingofshapesforextrabackupsupportthathelpthecustomerandcanincreasecompetitivebarriers 2nd-Proceduraltrendscreatemoreneedforbackup ***长病变中应用XBguiding的趋势。与XB和XBLAD的区别在：弧度更贴合血管壁的变化，因此能够适应更多情况下的开口，包括向上，向下等，自我调节性是比较高的Medtronic的EBU和我们的XBC最为接近，所以在扭转EBU时，可先让客户逐渐适应XBC。**于Amplatz相比，XBRCA的第一个弯相对较为平缓。所以更适用于向上开口病变。EBU是否有用于右冠的*EBU(ExtraBackUp)Catheterusedforleftcoronaryarteries.RBU(RightBackUp)Catheterusedforrightcoronaryarterieswithlateraltoinferiortakeoffs.Broadsecondarycurveallowstheguidetobracefirmlyagainstthecontralateralaorticwallforsuperiorback-upsupport.RequiresminimummaneuveringforsuperbcoaxialengagementoftheLM,LCXorLADbranches.AslightpushforsuperiortakeoffandLADorientation.AslightpullforinferiortakeoffandLCXorientation.DisengagessmoothlyandatraumaticallyintheJudkinstradition.UniqueEBUcurvedesignallowsJudkinsorAmplatzengagementstyles.Easesstentdeploymentbyprovidingavirtuallyfrictionlesspaththroughtheextra-relaxedprimarycurvesegment.*Themostimportantthinginselectingaguideischoosingonethatcangiveyouco-axialalignmentwiththeartery.Thelesionanatomywillhelptodeterminewhatkindofguidecatheterwouldbebestfortreatment.* TheaorticrootiscomprisedoftheSinusofValsalvaandthetubularportionoftheascendingaorta.TheostiaofthecoronaryarteriesarelocatedbehindtheaorticcuspsnearthetopoftheSinusofValsalva.Thecoronaryostialoriginsarethepointsatwhichtheostiumisattachedtotheaorticroot.Deviationsfromthetypicaloriginarehighorigin,bypassgraftorigin,andposteriororanteriororigin.* Normalaorta:Theaortahasanormalcurvatureanddiameterof3.5cmto4.0cm.Thenormalaorticconfigurationisfoundin60to70percentofallpatients.Narrowaorta:Theaorticarchhasaverytightcurveandasmallerdiameter(lessthan3.5cm).Narrowaorticarchescanmakeadvancingguidingcathetersandinterventionaldevicesmoredifficult.Softguidecatheterscanpartiallycompensateforthetightcurveinthearch.Smallerleftcoronarycathetersareusuallyselectedinthesepatients.Dilatedaorta:Theaorticarchisatamorerelaxedangle.Thediameterisgreaterthan4.0cm.Largerleftandrightcathetersareusuallyselectedinthesepatients.* Thesizeoftheaorticrootaffectsthecurvesizeofthecathetertobeused.Theaverageaorticrootgenerallyrequiresa4.0cmcurveguidecatheter,eitheranFL/JLorEBUfortheLCAoranFR/JRfortheRCA.Alargeraorticrootwouldrequirealargercurvedcatheter,suchasanFL/FRorEBU4.5or5.0toprovideadequateback-upsupportfromtheoppositeaorticwall,andenoughlengthtoproperlycannulatetheostium.AnarrowedaorticrootwouldrequireasmallerFL/FRorEBUcurve,suchasa3.0or3.5.Thecurvenotonlyaffectsback-upsupport,butalsodirectstiporientation.Ashorterdistancebetweentheprimaryandsecondarycurveshasatendencytoallowthecathetertomovefartherdownintotheaorticroot,orientingthetipmoresuperiorly,whilealargercurvewillsithigherintherootandtendtoorientthetipmoreinferiorly.Duringthediagnosticprocedure,oneshouldnotehowthediagnosticcathetersitsintheaorta.Thediagnosticcatheteronlyhastositonthelipoftheostiumtoinjectdyevs.theneedforaguidingcathetertoprovidesupport.*Iftheguidecatheteristoolong,thetipwillassumeaninferiorposition.Theguidewirewillthenfollowtheangleofthecurve(downward)possiblysubselectingtheLCX.* Iftheguidecatheteristooshort,thetipwillassumeasuperiorposition.Theguidewirewillthenfollowtheangleofthecurve(transverse/upward)possiblysubselectingtheLAD.*Thecoronaryarteryostiumcanvaryinplacementintheascendingaorta.Thisslideshowsthetypesofvariation.Coronaryostiallocation:high,low,anterior,posteriorCoronaryostialorientation:superior,lateral,inferior,shepherd’scrook(RCA’sonly)* Lateral:departsatahorizontalangle(90o).Inferior:departsatadownwardangle(45o-60o).Ifchoosingalongercurve,thelongerdistancebetweentheprimaryandsecondarycurveallowsthecathetertositslightlyfartheruptheaorticroot,positioningthetipmoreinferiorly.Superior:departsatanupwardangle(90o-120o).Ifchoosingashortercurve,theshorterdistancebetweentheprimaryandsecondarycurveallowsthecathetertositslightlyfartherdowntheaorticroot,positioningthetipmoresuperiorly.*Allowparticipantstoidentifyostialtakeoffsbeforebringinglabelsontoscreen.Angiographicviewsdepictinglateral,inferiorandsuperiorleftcoronaryarterytakeoffs.Pleasenotethattheangiographicprojectionusedcouldaltertheseimages,dependingontheangleofthecamera.AlloftheseappeartobeLAOswiththespineandcatheterinthesameposition.RAOviewsdeterminethetakeoffangleoftheleftcoronarysystem.RAOviewsdeterminecoaxialengagementofthetipintheleftmaincoronaryartery.*Allowparticipantstoidentifyostialtakeoffsbeforebringinglabelsontoscreen.Thisslideshowsthecommontakeoffanglesfortherightcoronaryartery.* TherearetwocommonanatomicvariationsassociatedwiththeRCA,aninferiortakeoffandaShepherd’sCrooktakeoff.AShepherd’sCrooktakeoffiswhenthecoronaryarterydepartstheaortaatanupwardangle,thenmakesasharploopdown.Thecoronaryisshapedlikethetopofashepherd’sstaff.ThemostdifficultofthesevariationsisaShepherd’sCrookwithaveryshortinitialorigin.* Twotypesofgraftsareusedtobypassthecoronaryarteries:saphenousveingrafts(SVG)andinternalmammaryartery(IMA)grafts,andfreeradialartery.Bypassgraftspresentcannulationdifficultiesbecauseoftheirunusualorientationandlocation.Mostcathetersaredesignedfornativevesselsthatcomeoffoneofthecusps.Thesecathetersaredesignedtocomeovertheaorticarchandorientinaspecificmanner.TheSVGspresentsomeuniqueproblemswhenitcomestoengagement.Thesaphenousveinisremovedfromthelegandattachedproximallytotheaortaanddistallytothecoronaryarterybeyondthelesion.Becauseoftheshortdistancebetweentheaorticarchandtheoriginofthegraft,theguidecathetermustspantheaorta,restingwithitssecondarycurveontheposteriorwallanditstipontheanteriorwalltoprovideastableplatformforadvancingtheballooncatheter.TheIMAarisesfromtheleftsubclavianarteryinproximitytotheheart.TheIMAisdissectedawayfromthechestwall,thedistalendisanastomoseddirectlytothecoronaryarterydistaltothelesionwhiletheproximalendmaintainsitsoriginaltakeofffromthesubclavianartery.* Angiographicviewsdepictinginternalmammaryandsaphenousveingrafttakeoffs.**内乳动脉开口如果无明显成角，JR4即可到达，如果开口明显成角，则要选择专用的内乳动脉桥血管。*32*1***导管扭曲于腋动脉，无法推送、回撤，送入两个硬导丝后撤出。指引导管操作要轻柔，切忌过度旋转、暴力推送导管。*急性下壁心肌梗死，左冠造影回旋支缺如。*CYPHERSELECT3.0*33mm到左主干和LAD近段病变处，沿LCX中导丝送CYPHERSELECT2.75*23mm到左主干和LCX近段病变处*对角支：Firebird3.0*18mm前降支：3.5*33mmFirebird经6F指引导管Kissing扩张*6FAL1GUIDINGCATHETERINTERMEDIAT引导导丝在1.5×15mmPLEON球囊支撑下通过病变扩张后置入4.0×15mm的MOTION支架*3.5*32mmTAXUS支架至桥血管近段病变处，支架中段明显凹腰征，残窄30%；送3.0*20mmTAXUS支架