2 English reference angiography
3 operation name angiography
4 The indications of angiography are as follows:
1. Primary vascular diseases (such as vascular occlusive disease, aneurysm, arteriovenous malformation, arteriovenous fistula, etc.). ).
2. Diagnosis and localization of small vascular tumors (such as parathyroid adenoma and pancreatic cell adenoma). ).
3. Determine and judge the anatomical position of blood vessels before operation (such as vascular reconstruction, local tumor resection and organ transplantation).
4. Diagnosis and treatment of diseases related to surgery, especially vascular complications.
5. The implementation of percutaneous vascular interventional diagnosis and treatment technology (such as vascular repair, embolization, injection, etc. ).
Advanced interventional examination and treatment of important cardiovascular diseases (such as vascular ultrasound, coronary endoscopy, intracoronary Doppler ultrasound, percutaneous transluminal coronary angioplasty and stent implantation).
5 contraindications 1. Absolute contraindication? Patients with multiple organ dysfunction and clinical instability.
2. Relative contraindications
(1) recently suffered from myocardial infarction, severe arrhythmia and severe serum electrolyte disorder.
(2) There was a history of significant contrast agent allergy in the past.
(3) Moderate renal insufficiency.
(4) Abnormal coagulation function or coagulation dysfunction caused by some reasons.
(5) Patients with congestive heart failure or severe respiratory diseases should not lie down quietly when taking pictures.
(6) Due to the recent history of X-ray, barium meal, etc. (because barium agent stays in the abdomen, abdominal organ radiography cannot be clearly determined).
(7) Pregnancy: Radiation has teratogenic effect on fetus.
6 ready 1. Ordinary contrast agent
(1) sodium bis (acetamide) 3 iodobenzoate (hypaque).
(2) The mixed solution of sodium bis (acetamide) 3 iodobenzoate and methyl glucosamine salt.
(3) Sodium diatrizoate and meglumine diatrizoate.
2. Carefully review and proofread the medical records and all the clinical data examined by the patients, and at the same time require the patients to clearly fill in the "Description and Consent Form" (Form 1A ~ C) before operation.
(2) The following tests should be done: BUN, serum creatinine (Cr), prothrombin time (PT), partial thromboplastin time (APTT), platelets, etc.
(3) limit drinking water within 8 hours before the implementation of radiography, and take medicine orally as usual (radiography in the morning, fasting at breakfast; Chinese food will be fasted in the afternoon.
(4) Diazepam 10mg ~ 20 minutes before angiography, and the dose should be reduced in the elderly and children.
(5) You must urinate before entering the comparison room.
(6) When sending to the comparison room, you should also bring medical records, various inspection materials and ID cards. Relatives should wait outside.
Method 7. 1. 1. Types and methods of arteriography (1) Retrograde femoral artery catheter method and Seldinger method.
(1) disinfection, preparation of puncture site (shaving, etc. ), laying hole towel.
② Touch the femoral artery pulse at the inguinal ligament.
Because of the deep position, the femoral vein is not visible on the skin surface. This vein is 2 ~ 3 cm below the inguinal ligament and 0.5 ~ 1.0 cm inside the femoral artery. Pierce the skin with a percutaneous puncture needle at an angle of 40 with the skin, plug the cover and pull out the movable cannula sheath, and see that there is blood rushing in the arterial blood vessels.
③ Insert the guide wire into the predetermined imaging site, after pulling out the guide wire, insert the catheter into the imaging site (i.e. the lesion site), and take continuous photography immediately after injecting the human contrast agent (generally about 20ml each time).
7.2 2. Puncture the femoral artery along the femoral artery with Seldinger needle. The basic method is the same as above. When you feel a pulse in the femoral artery (slightly pulsating through the Seldinger needle), continue to push it into the blood vessel. Then pull out the inner trocar and see the blood gushing from the outer trocar. The dosage and method of contrast agent are the same as before.
7.3 3. Antegrade femoral artery puncture is used to cut the skin (different from the puncture site of femoral artery), and different parts of different arteries are selected according to the affected area. First, disinfection, skin incision, arterial separation and acupuncture were performed. The rest of the method is the same as before.
7.4 4. Puncture the left axillary artery, or use the left axillary artery, or subclavian artery to reach the patient's site for angiography, or remove the thrombus, etc. The imaging method is the same as before.
7.5 5. Patients with cranial arteriography lie on their backs and their heads are overstretched. At the joint of sternocleidomastoid muscle 4 ~ 5 cm (the inner edge of sternocleidomastoid muscle), where the carotid artery pulsates obviously, a sterile hole towel is placed and the needle is inserted into the blood vessel. After the needle enters the artery, the operator feels that the needle is beating with the artery. At this time, pull out the needle core, immediately gush out blood, then insert a blunt needle core into the needle core, and then push the puncture needle forward 1.5 ~ 2.0 cm. Correct the head position again and ask the patient to hold his breath. Immediately inject 8 ~ 10 ml of contrast medium from the puncture point with a syringe filled with contrast medium (at the discretion of the child) at a speed of 5ml per second, and take photos when the contrast medium is injected12.
7.6 6. Visceral arteriography mainly refers to celiac artery and superior mesenteric artery angiography. The angiographic method is the same as the above-mentioned arterial angiography method. In other words, the seldinger intubation method was used. At 12 thoracic vertebra, rotate the catheter so that the tip points to the front of the abdomen, and then slowly move down, and the top of the catheter is covered like a nail. If there is resistance at this time, it means that the catheter has entered the superior mesenteric artery. Quickly inject 5 ml of contrast agent through the catheter. If the blood vessels are filled in figure 8 (the left splenic artery is thick and the right hepatic artery is thick), it means that the catheter has entered the celiac artery. When the blood vessel filling is scattered in multiple sectors, it means that the catheter is in the superior mesenteric artery.
Note: after successful venipuncture, the blood flowing out is mostly black and slow; But the blood flowing out of the artery is bright red, fast and spewing out. After venipuncture, generally press 10 ~ 15 minutes; If arterial puncture is used, it should be pressurized for about 20 ~ 30 minutes after the end.
7.7 7. Postoperative management after arterial puncture (1) compression method
① The cooperation of patients is very important.
② After the catheter was removed, about 20ml of blood retrograde into blood vessels. Guide wire should be inserted before pulling out pigtail catheter.
(3) Wear gloves when compressing blood vessels (after pulling out the catheter). At the same time, it should be padded with sponge or gauze, and there should be no blood.
④ Pressing method: press the puncture site with the middle finger, press the upper part of the puncture site with the index finger and press the lower part with the ring finger, that is, press the three fingers together.
⑤ Grasp the pressure when pressing the blood vessel, so that the pulse will not disappear and the terminal pulse can be really felt.
6. Pay attention when compressing blood vessels? Effectively compress 15 minutes, then slowly decompress, compress for another 5 minutes, and then stop. Don't stop at once to prevent bleeding.
All landowners once found bleeding again, should be repeatedly pressed for 20 minutes.
⑧ At the end of pressing, all peripheral beats should be touched and compared with those before operation.
(2) When the lower limbs are straight, you should lie still in bed for 8 hours with your head slightly raised.
Check the puncture site for bleeding: once every 15 minutes for the first 4 hours, once every 30 minutes for the next 4 hours, and then once every 4 hours for bleeding and hematoma.
(3) Blood pressure and pulse 1 time every 30 minutes for the first 4 hours, and 1 time every 4 hours.
(4) 500 ml of 5% sugar water and 500 ml of normal saline are intravenously dripped at the speed of 250 ml per hour, and then 500 ml are added at the speed of 150 ml/hour/hour respectively. Pay attention to the heart, lung and renal function of the patient during intravenous drip.
(5) After operation, you should be told to drink more water, and the urine output should be ≥600ml. If you have difficulty urinating, you should insert a catheter.
(6) The preoperative diet can be resumed the next day.
(7) Use of heparin
It should be given 6 ~ 12 hours after operation.
(8) hematoma or bleeding at puncture site (when it is difficult to stop bleeding)
(1) There is a hematoma in the groin, or an indelible blood induration. It is necessary to observe its increase and decrease and deal with it as appropriate.
② When there is bleeding at the puncture site that is difficult to stop bleeding, attention should be paid to the weakening or disappearance of pulse and limb nervous system symptoms. When a retroperitoneal hematoma is suspected, you should contact a surgeon.
7.8 8. Incidence rate of complication prevention (1): It is related to the patient's age and proficiency in imaging operation, as shown in Table 2.
(2) Thrombosis
① It is usually due to the catheter, that is, various factors, such as the catheter is too thick (compared with the arterial lumen), or the catheter material is poor, and the length of blood stains on the catheter surface (50% patients have meaningful thrombus attached to the catheter surface after angiography) and so on.
② Thrombosis is related to the degree of intimal injury, vasospasm and coagulation.
(3) Bleeding
① Compression of artery at puncture site is the most important; The puncture site should be correctly grasped in the upper thigh; Generally, the compression time at the upper and lower ends of the puncture site is short, or the compression technique is not well mastered.
② Generally, it is pressed above the skin puncture point (that is, one finger is pressed at the upper end of the skin puncture point and the other two fingers are placed at the lower end of the puncture point (square); The compression intensity should not completely block the blood flow but touch the pulse of peripheral blood vessels.
③ If the puncture angle of the puncture needle is parallel to the skin, it is easy to puncture the posterior wall of femoral artery, which is located above the inguinal ligament. At this time, it is easy to form a retrovascular hematoma.
④ Pseudoaneurysm: puncture of superficial femoral artery should be avoided (the most common puncture position is too low). At this point, after the catheter is pulled out, it should be punctured carefully according to the operation requirements (pressurization is slightly more difficult than normal people).
⑤ Embolization: To prevent sequela of peripheral embolism.
Once thrombus is confirmed, thrombectomy should be considered immediately.
B. If clinical symptoms of thrombosis are suspected, and the symptoms are getting worse, thrombolytic therapy should be chosen.
8 precautions 1. Attending doctors should pay attention to the following points:
(1) Patients who are using heparin: APTT should be kept in the normal range (the ratio compared with the normal value is 1.2 ~ 1.5). At this time, heparin drip should be stopped 4 hours before puncture. At the same time, heparin continued to be used for 6 ~ 12 hours after local vascular compression after extubation.
(2) Patients using dicoumarin anticoagulants: If possible, these drugs should be stopped a few days before arterial puncture, and patients with prolonged PT should be given fresh freeze-dried plasma (FFP) or intramuscular injection of vitamin K 25~50mg (so that PT ≤ 15s) 4 hours before puncture.
(3) Patients who use antiplatelet preparations: Patients who undergo femoral artery puncture or axillary artery puncture should have a platelet count of ≥ 75,000/mm3.
(4) Patients with insulin-dependent diabetes mellitus: the dosage of insulin is halved in the morning, and the dosage on the day of examination is the same as usual. Food is taken from the mouth, and the dosage of insulin in the afternoon depends on the results of blood sugar (or urine sugar) examination after returning to the ward; When a fatal allergic reaction occurs during the operation, it must be neutralized with protamine; For diabetic patients, no matter whether they have kidney disease or not, as long as they are in danger of causing acute tubular necrosis, at least fluid should be added.
(5) Patients allergic to lidocaine (local anesthesia): Pay attention to the following points:
(1) Local infiltration lidocaine allergy test is negative, so arterial puncture local infiltration method can be adopted, or the following methods can be adopted:
② If the skin test of procaine hydrochloride is negative, local anesthesia can be used, or:
③ Infiltration anesthesia mixed with normal saline.
2. Matters needing attention when using drugs
(1) Patients with severe coronary heart disease or cerebrovascular disease should avoid giving drugs to reduce cardiac output if their blood pressure is low.
(2) Prevention of spasm: Avoid using drugs that lower the threshold of spasm (such as pethidine). ).
(3) Liver cell damage: For example, avoid using barbiturates to prevent liver cell damage.
(4) Pheochromocytoma: People with unstable blood pressure should take alpha blockers.
(5) Multiple myeloma and diabetic nephropathy? In order to prevent acute tubular necrosis, fluid must be added.