Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3597_Библиотеки_им_академика_М_И_Перельмана
.pdf
Right Left
https://t.me/med1917
3 —
Coronary Angiography and Ventriculography 123
Secondary
curve
Primary
curve
Secondary
curve
Primary curve
Tertiary
curve
Figure 3-16 Judkins right (JR) and Judkins lef t (JL) coronary catheters,
identif ying primary, secondar y, and tertiary cur ves of each catheter. These
curves are designed to facilitate entr y into the ostia of each coronary ar tery.
Tertiary
curve
A
Figure 3-17 Judkins lef t (JL) coronary catheter position. A, Correct align-
ment. B, Incorrect position and overinsertion. (From King SB, Douglas JS
Jr: Coronar y arteriography and angioplasty, New York, 1985, McGraw-Hill.)
catheter in the same patient angles upward and a larger (5 cm) catheter angles downward into the coronary cusp. When the coronary
ostium cannot be seated correctly or placed in a stable position, the
catheter should be replaced with a better-fitting catheter rather than
aggressively manipulated into the coronary artery (Fig. 3-17). A slight
rotation of the catheter may be necessary to improve alignment of the
catheter tip with the LM coronary trunk.
B
124 3 —
https://t.me/med1917
Coronary Angiography and Ventriculography
A
C
Figure 3-18 Judkins right (JR) coronar y catheter position. A, Correct align-
ment. B, Tip subselectively in conus arter y. C, Tip wedged in proximal stenosis. D, Tip impinging on lateral vessel wall. (From King SB, Douglas JS Jr:
Coronary arteriography and angioplasty, New York, 1985, McGraw-Hill.)
The JR coronary catheter is sized by the length of the secondary
curve and is available in 3.5-, 4-, and 5-cm sizes. In most cases, the
4-cm catheter is adequate. The JR catheter is advanced into the
ascending aorta (usually with LAO projection) with the tip directed
caudally (Fig. 3-18).
The RCA can be entered in most cases by one of two
maneuvers:
1. Advance the catheter into the right coronary cusp and rotate the
catheter 45 to 90 degrees clockwise as the tip is pulled back 2 to
3 cm. As the right coronary orifice is engaged, the fluoroscope
shows rotation of the tip toward the right coronary cusp and downward motion of the catheter.
2. Advance the catheter tip to 2 to 4 cm above the valve. When the
catheter is rotated clockwise for 45 to 90 degrees, the tip rotates
toward the right cusp and descends approximately 1 to 2 cm,
engaging the right coronary ostium from above.
If the coronary ostium is not engaged, the maneuvers are repeated,
starting at a slightly different level each time. A brief contrast media
injection into the right coronary cusp may help the operator direct the
catheter. A slight but firm push-pull motion on the catheter is necessary to translate rotational motion at the hub down to the tip.
If stored rotational energy is not released by a small counter rotation after seating, the catheter may spring out of the right coronary
ostium when the patient takes a deep breath. After seating, the operator checks for pressure damping associated with ostial stenosis or
conus branch cannulation.
B
D
Amplatz-Type Catheters
The left Amplatz-type catheter is a preshaped half-circle with the
tapered tip extending perpendicular to the curve (Fig. 3-19). Amplatz
catheter sizes (left 1, 2, and 3 and right 1 and 2) indicate the diameter
of the tip curve. In most normal-sized adults, no. 2 left and no. 1 right
https://t.me/med1917
3 —
Coronary Angiography and Ventriculography 125
A
B
Figure 3-19 Catheterization of the coronary arteries (Amplatz technique,
left anterior oblique [LAO] projection). A, Catheterization of the left coronary
artery (LCA). 1, The lef t coronar y catheter is advanced until the secondary
curve rests in the noncoronary posterior aortic cusp and its tip points to
the left coronary ostium. 2, The catheter is gently advanced and retracted
until the left coronary ostium is engaged. B, Catheterization of the right
coronary ar tery (RCA). 1, The right coronary catheter initially may point to
the left coronary sinus. 2, It is withdrawn slightly and rotated clockwise until
the tip points toward the RCA and the secondar y curve rests against the
left aortic cusp. 3, The RCA is engaged as the catheter is advanced and
withdrawn. (From Tilkian AG, Daily EK: Cardiovascular procedures: Diagnos tic techniques and therapeutic procedures, St Louis, 1986, Mosby.)
1 2
1 2 3
(modified) Amplatz catheters give satisfactory results. In the LAO projection, the tip is advanced into the left aortic cusp. Further advancement of the catheter causes the tip to move upward into the LM aortic
trunk. It may be necessary to push Amplatz catheters down to move
the tip up and out of the ostium to disengage the catheter from the LM
ostium. If the catheter is pulled instead of being advanced, the tip
moves downward and into the LM or CFX artery. Unwanted deep cannulation of the CFX artery might tear this branch or the LM aortic
trunk. The incidence of coronary dissection is higher with Amplatz
catheters than with Judkins-type catheters.
The AR mod catheter has a smaller but similar hook-shaped
curve. The catheter is advanced into the right coronar y cusp. As with
JR catheters, the catheter is rotated clockwise by 45 to 90 degrees. The
same maneuver is repeated at different levels until the RCA is entered.
After coronary injections, the catheter may be pulled, advanced, or
rotated out of the coronary artery.
Multipurpose Catheters
MP catheters are those that are primarily straight or slightly angled
with an end hole and two side holes placed close to the tapered tip.
An MP catheter can be used for left and right coronary injections.
Extra care is required if this catheter is used for ventriculography.
126 3 —
https://t.me/med1917
Coronary Angiography and Ventriculography
Special-Purpose Femoral
Angiography Catheters
The right coronary vein graft catheter is similar to a JR catheter but
has a wider, more open primary curve that allows cannulation of a
vertically oriented coronary artery vein graft. The left coronar y vein
graft catheter is similar to the JR catheter but has a smaller and sharper
secondary curve that allows easy cannulation of LAD and left CFX vein
grafts, which are usually placed higher and more anterior than right
coronary grafts with a relatively horizontal and upward takeoff from
the aorta.
The internal mammary artery (IMA) graft catheter has a peculiar
hook-shaped tip configuration that facilitates the engagement of IMA
grafts, especially in patients with a vertical origin of the IMA.
Preformed Coronary Catheters from the
Radial Artery Approach
Coronary Catheters from the Radial Artery Approach
Cannulation of the LCA using a preformed catheter is easier than cannulation using an MP catheter. JL and JR coronary catheters can be
used through the left or right arm with satisfactory results. Compared
with the femoral technique, a JL3.5 catheter may be necessary with
the left radial technique.
An Amplatz catheter can be used effectively from either the right
or the left arm. This catheter is manipulated in a fashion similar to that
described for the femoral approach. The coronary catheters can be
removed without a guidewire, but the pigtail ventriculography catheter
should be removed over a guidewire to straighten the pigtail loop and
prevent it from kinking or lodging in the subclavian or axillary artery.
A special consideration from the arm approach is negotiating a
sharp caudal turn near the origin of the right carotid arter y. To facilitate passage into the central aorta, the patient should be instructed to
take a deep breath to pull down the great vessels and heart while the
operator advances the guidewire and catheter. The manipulations to
seat the preformed radial catheter are similar to those for the Amplatz
and MP techniques (see Fig. 3-19, C).
Radial Universal Catheters
Catheters used for coronar y angiography from the radial approach are
called generically “universal catheters” because they can engage both
the left and right coronary ostia. Among the most common is the
“Jacky Catheter” (see Fig. 3-15, B). This catheter is positioned much
like Amplatz maneuver catheters are positioned. The advantages
of the Jacky and other universal catheters are reduced catheter
exchanges with reduced potential for radial/brachial artery spasm,
radiation exposure, and procedure time. The Jacky has a less acute
terminal curve than the Tiger (TIG) catheter and has a tendency to
sit more coaxially with the LMCA and engage the RCA with fewer
movements.
Although some operators perform ventriculography through universal catheters because there are side holes near the catheter tip, we
do not recommend this practice (see end of the end-hole left ventricle
[LV] gram, page 95 and figure 3-22). Certainly, a hand injection for
ventriculography may be inadequate. In addition, the Jacky catheter
tip frequently points directly toward the anterior wall of the LV, causing
ventricular ectopy and possible perforation.
Saphenous Vein Graft and Internal Mammary Artery
Angiography Catheters
The right coronary vein graft catheter is similar to a JR catheter but
has a wider, more open primary curve that allows cannulation of a
https://t.me/med1917
3 —
Coronary Angiography and Ventriculography 127
vertically oriented coronary artery vein graft. The left coronar y vein
graft catheter is similar to the JR catheter but has a smaller and sharper
secondary curve that allows easy cannulation of LAD and left CFX vein
grafts, which are usually placed higher and more anterior than right
coronary grafts with a relatively horizontal and upward takeoff from
the aorta.
The IMA graft catheter has a peculiar hook-shaped tip configuration that facilitates the engagement of IMA grafts, especially in patients
with a vertical origin of the IMA.
Ventriculography Catheters
(Pigtail, Halo, Multipurpose)
The pigtail catheter is the safest choice for ventriculography and is the
most commonly used ventriculography catheter, with a preshaped tip
making nearly a full circle ~1 cm in diameter. There are 6 to 12 side
holes on the straight portion of the catheter above the curve. To enter
the LV, the pigtail catheter is advanced to the aortic valve. The loop is
positioned to the left in the RAO projection (resembling a “6”), and
the catheter is pushed against the valve to make a U shape that facilitates entry into the ventricle during deep inspiration. Inside the ventricle, the catheter can be placed in front of the mitral valve with the
loop directed toward the apex, away from the valve (in the RAO position). A slight rotation, advancement, or withdrawal may be necessary
to find a “quiet” position (one that does not cause frequent premature
ventricular contractions) (Fig. 3-20). An angled (145 degrees) pigtail
catheter may be helpful for this purpose, especially for horizontally
oriented hearts.
A Halo catheter is a novel 5-French (5-F) catheter with a perpendicular helical tip with an inwardly and upwardly directed tip. The
side holes are located on the helix and produce equivalent left ventriculograms with minimal ectopy because the contrast jets are
directed inward and not to the myocardium (Fig. 3-21). It is excellent
for measuring distal LV chamber pressure in hypertrophic cardiomyopathy because, in contrast to a pigtail catheter, there are no holes
along the shaft to create a falsely low distal intraventricular pressure
gradient.
3
Figure 3-20 Method of lef t ventricle (LV) catheterization. 1, Having crossed
the aortic valve, the pigtail catheter is in position. 2, The catheter is withdrawn 2 to 3 cm and rotated 70 to 90 degrees counterclockwise. 3, The
coiled loop is in the inflow tract of the mitral valve. 4, If the catheter moves
excessively in this position, it should be advanced until it is stable. (From
Judkins MP, Judkins E: Coronary arteriography and left ventriculography:
Judkins technique. In King SB III, Douglas JS Jr, editors: Coronar y ar teriography and angioplasty, New York, 1985, McGraw -Hill.)
1
2
4
128 3 —
https://t.me/med1917
Figure 3-21 Halo ventriculography catheter. Side holes are contained only
within the spiral, which is directed inward to reduce premature ventricular
contractions.
Coronary Angiography and Ventriculography
Incorrect Incorrect
Correct
A
Figure 3-22
(MP) end- hole catheter in the right anterior oblique (RAO) projection. Correct
positioning requires the catheter tip to be free in the center of the ventricle,
near the tip of the papillar y muscles, and aiming toward the apex. If it is
touching the inferior or inferolateral wall (left), it should be rotated clockwise.
If it is touching the anteroseptal wall (right), it should be rotated counterclockwise. For ventriculography, use of end-hole catheters should be abandoned in favor of pigtail catheters for improved safety. (From King SB,
Douglas JS Jr: Coronary arteriography and angioplasty, New York, 1985,
McGraw-Hill.)
In the past, the MP and other end-hole-type catheters have been
used for ventriculography. This and other end-hole catheters are no
longer recommended for ventriculographic studies because the highpressure contrast jet may produce ventricular tachycardia (VT), contrast injection in the myocardial tissue (contrast staining), or ventricular
perforation (Fig. 3-22).
A, Catheterization of the left ventricle (LV) with a multipurpose
Common Problems in Accessing and
Cannulating Coronary Arteries and Grafts
Left Coronary Artery
Short Left Main, Separate Ostia for Left Anterior Descending
and Circumflex Arteries. In patients with a short LM artery segment
or separate ostia, it may be necessary to cannulate the LAD and CFX
arteries separately. Using a smaller JL catheter (i.e., JL3.5, not JL4)
often permits selective cannulation of the LAD artery. Slight withdrawal and clockwise rotation or use of a larger JL5 catheter also
favors cannulation of the CFX artery. An Amplatz-type catheter is
especially useful to cannulate the CFX artery separately but must be
used with care to avoid artery dissections.
B-1a
https://t.me/med1917
B-1b
B-1c
B-1d
Figure 3-22, cont’d
in the RAO projection followed by power contrast injection with an ACIST
medical injector, 13 mL/sec to maximal volume of 45 cc (less was injected
when staining was noted). The right frame shows beginning of myocardial
staining. 1b, Continued injection frames more staining of the LV. 1c, Dense
fixed staining of contrast into the myocardium. When viewed in the left
anterior oblique (L AO) projection (see B, 2a frames), one can see that this
catheter was positioned into the lateral wall of the LV. 1d, Persistent contrast stain after the end -hole ventriculogram.
B, 1a, Lef t to right, A 5- F Jacky catheter positioned
(Continued)
130 3 —
https://t.me/med1917
B-2a
Coronary Angiography and Ventriculography
B-2b
Figure 3-22, cont’d
the 5 -F Jacky catheter recorded during the power contrast injection as in
B, 1a. First and second frames show the beginning of myocardial staining.
2b, Continued deep penetration of contrast media into the myocardium
without perforation into the pericardial space with a dense fixed staining of
myocardium. Fortunately, there was no clinical sequalae associated with
this procedure. An echocardiogram, per formed urgently before the patient
left the laboratory, showed no pericardial effusion or wall motion abnormality. (B, Reprinted with permission from the Cath Lab Digest, copyright HMP
Communications.)
High Left Coronary Artery Takeoff. An unusually high origin of
the LMCA from the aorta can usually be cannulated with use of an MP
catheter or an Amplatz-type catheter (e.g., AL 2). A long, tapered-tip
MP catheter may be used to cannulate the high-origin LM trunk
through the brachial approach.
Wide Aortic Root. In patients with a relatively horizontal or wide
aortic root with upward takeoff of the LMCA, a large-curve JL5 or JL6,
AL coronary, or MP catheter may be required.
B, 2a, Left to right, Simultaneous RAO LV gram with
Right Coronary Artery
The origin of the RCA shows more variation than that of the LCA. When
encountering difficulty in locating the ostium, a contrast injection low
into the right coronar y cusp helps direct the catheter. If the RCA is not
seen with this flush injection, it may be totally occluded or may originate anteriorly on the aorta or from the left sinus of Valsalva. In this
case, the orifice is usually located above the sinotubular ridge. An AL
catheter or a left bypass graft catheter can be used successfully to
engage the RCA orifice located anteriorly or in the left cusp. Minimal
anterior displacement of the RCA from the right coronary sinus is more
common. In this case, the JR catheter tip may not be directed toward
the right but looks foreshortened in the familiar LAO view. Directing
https://t.me/med1917
the catheter tip to the right in the usual fashion using the lateral view
permits easy cannulation of the anteriorly directed right coronary
orifice. Rarely, an aortogram is necessary to confirm the presence of
the RCA.
Wide Aortic Root. In a patient with a horizontal and wide aortic
root, cannulation of the right coronary orifice and right coronary cusp
may require an Amplatz or MP catheter.
High Right Coronary Artery Takeoff. A relatively high origin of
the RCA may require an AL or AR mod catheter. The most common
coronary anomaly (see page 137,
nary Anomalies) is the CFX artery originating from the RCA or right
coronary cusp and coursing posteriorly and downward. This location
may be cannulated easily with use of an AR catheter.
3 —
Coronary Angiography and Ventriculography 131
Angiography of Common Coro-
Assessment of Coronary Stenoses
The degree of an angiographic narrowing is estimated as the percentage lumen reduction of the most severely narrowed segment compared with the adjacent angiographically normal vessel segment, seen
in the worst x-ray projection. Because the operator uses visual estimations, an exact evaluation is impossible; in general, there can be a ±
20% variation between readings of two or more experienced angiographers. Stenosis severity alone should not always be assumed to be
associated with abnormal physiology (blood flow) and ischemia.
Moreover, CAD is a diffuse process, and thus, minimal luminal irregularities on angiography may represent significant albeit nonobstructive CAD at the time of angiography. The stenotic segment lumen is
compared with a nearby lumen that does not appear to be obstructed
but that may have diffuse atherosclerotic disease (Fig. 3-23). This
explains why postmortem examinations and intravascular ultrasound
(IVUS) imaging describe much more plaque than is seen on angiography. The percent diameter is estimated from the angiographically
normally appearing adjacent segment. Because coronary arteries normally taper as they travel to the apex, proximal segments are always
larger than distal segments, often explaining the large disparity among
several observers’ estimates of stenosis severity.
Percent diameter is the common measurement reported to convey
stenosis severity. Recall that area of stenosis is greater than diameter
stenosis. Estimates of narrowing assume that the lumen is circular, but
the lumen is more often eccentric. Although the practice has been to
report “exact” measurements (even when using only the naked eye),
realistically and for practical purposes, there are only four categories
of lesion severity:
1. Minimal or mild CAD, narrowings <50%
2. Moderate, stenosis between 50% and 70%
3. Severe, stenosis between 70% and 95%
4. Total occlusion (100%)
Technical note: Stenosis anatomy should not be confused with
abnormal physiology (flow) and ischemia, especially for lesions 40%
to 70% narrowed. For nonquantitative reports, the length of a stenosis
is simply mentioned (e.g., LAD proximal segment stenosis diameter
25%, long or short). Other features of the coronary lesion may not be
appreciated by angiography and may require IVUS or optical coherence tomography (OCT) (Fig. 3-24).
Several different angiographic pathologies commonly seen during
coronary or peripheral vascular angiography include thrombus, dissection, aneurysms, and coronary fistualae.
A thrombus is defined as a lucency within a vessel or chamber
surrounded by at least three sides of contrast in an appropriate clinical
setting (e.g., acute coronary syndromes). In the coronar y vessels, a
thrombotic occlusion may totally block the flow of contrast and have
a meniscus appearance (Fig. 3-25, A).
132 3 —
https://t.me/med1917
Coronary Angiography and Ventriculography
Proximal Distal
A
Diameter
decrease
Angiographic
view (diameter)
Histologic
view (area)
Cross-sectional
decrease
B
Figure 3-23 A, Diagram of coronary arter y with stenosis (top) and corre-
sponding intravascular ultrasound (IVUS) images demonstrating diffuse
nature of coronary artery disease (CAD). B, The percent narrowing is com pared only with the “normal”-appearing angiographic lumen, which may not
be normal at all.
Extent
Severity
50%
50%
75%
75%
75%
95% 98%
88%
88%
0
25%
50%
25%
0
Composition
Complication
Figure 3-24
angiographic imaging and can be evaluated by intravascular ultrasound
(IVUS).
Angiographic features that may not be appreciated on cine-
Соседние файлы в папке Библиотека им академика М.И. Перельмана