1. Preoperative preparation
(1) Explain to the patient the matters that need to cooperate with the doctor during the operation, explain to the family members the possible complications that may occur during the operation
, and sign the consent form for the operation.
(2) Drugs: iodophor for sterilization, 1% lidocaine, heparin saline, contrast medium and rescue medicines.
(3) Arterial puncture needle and dilator sheath set, left coronary angiography catheter and right coronary angiography catheter
The catheter, commonly used Judkins, Amplatz-type catheter and **** with the type of catheter, etc., refers to the guide wire.
(4) Triple tee plate, pressure set, syringe.
(5) Cardiac monitor, defibrillator, temporary pacing system, endotracheal tube, assisted ventilation equipment.
2. Surgical approach
(1) Vascular access: femoral, radial or brachial artery can be used.
(2) Seldinger method percutaneous puncture of the artery and placement of the arterial sheath tube, discretionary administration of heparin 2000 ~ 3000
U, hypercoagulable state or operation with prolonged break-in (more than lh), additional heparin. Frequent aspiration of the arterial sheath side tube, observe
without thrombus obstruction.
(3) Deliver the catheter to the middle of the ascending aorta under X-ray fluoroscopy and guidewire guidance, not too deep to
avoid entering the coronary artery unknowingly. Once the catheter is in place, the guidewire is removed, air is removed, a triple triple
pass is connected, and the pressure curve is observed to confirm that it shows a good pressure curve.
(4) Left coronary angiography is usually performed first, usually in the orthostatic or left anterior oblique position, and the left coronary angiography catheter is slid downward along the wall of the main
artery into the left coronary sinus, and in most cases the catheter tip will automatically jump into the left main trunk. At this point, one should
first confirm that there is no abnormal change in the pressure profile, and then inject a small amount of contrast to confirm that the catheter is in the proper position (avoiding excessive
deepness or excessive apex wall of the catheter tip). If the catheter does not enter the left coronary artery, it can be entered by slight rotation with lifting of the catheter.
After confirming that the catheter is in the proper position, the C-arm is rotated, and the left coronary artery is visualized in various positions. Commonly used positions
include left anterior oblique, right anterior oblique, posterior anterior, and cephalic and pedal angular projection.
(5) Right coronary angiography is usually performed in the left anterior oblique position. The right coronary angiography catheter is sent down the aortic wall to the right coronary sinus, and the catheter is rotated in the clockwise direction to observe the pressure and catheter pulsation, which is combined with the injection of contrast medium to determine whether the catheter enters the right coronary artery anonymously or not. After confirming that the catheter is in the proper position, the C-arm is rotated to visualize the right coronary artery in a variety of positions
. Commonly used positions include left anterior oblique position and right anterior oblique position.
(6) At the end of the examination, the arterial sheath tube is withdrawn, and local compression is applied to stop bleeding, which usually requires 15 to 25 min of compression with
compression bandages. Vascular closure devices may be used as appropriate.
(7) Left coronary angiography via the radial artery can be performed with either a Juakins left (JL) or an Amplatz left-type catheter
catheter (AL).The AL is easier to maneuver, and it can be entered into the left coronary sinus under the guidance of a guidewire, turning the
catheter in an anticlockwise direction while pushing the catheter close to the opening of the left coronary artery, and then twisting the catheter clockwise. Normally the catheter
will automatically jump into the left coronary orifice. If it is too deep, the catheter head can be retracted
from the left main trunk by turning it counterclockwise again. Right coronary angiography can be performed with either a multipurpose catheter, a Judkins right (AR) or an AL catheter.The AL catheter
can also be turned around after doing the left coronary artery to do the right coronary artery, and a single catheter can be used to do both coronary arteries without having to
exchange catheters. In recent years, specially designed left and right coronary arteries*** type catheter, also widely used, with a catheter
completion of left and right coronary angiography.
3. Postoperative treatment
(1) For patients with localized compression for hemostasis, the limb on the puncture side should be braked for 10--24h, and sandbag compression should be applied for 6h. 24h
The patient's symptoms, vital signs, electrocardiogram, site of puncture, and peripheral circulatory status should be closely observed within 24h
.
(2) Encourage the patient to drink water or intravenous rehydration to promote the excretion of contrast medium. Pay attention to the correction of electrolyte disorders.
4. Complications and treatment
(1) Arrhythmia: common bradycardia, atrioventricular block, ventricular premature beats, and so on, related to intracoronary injection of
injection of contrast medium, mostly transient, can be instructed to cough to speed up the recovery of heart rhythm. A small number of patients with bradyarrhythmias
have to be treated with atropine or even pacing. Severe arrhythmias include ventricular tachycardia and ventricular fibrillation
most often associated with catheter-embedded coronary arteries. The catheter should be repositioned or withdrawn as soon as possible, and severe arrhythmias that cannot be
terminated by these treatments should be defibrillated with drugs or immediate electrical cardioversion therapy.
(2) Acute pulmonary edema or exacerbation of heart failure: the examination should be terminated and immediate resuscitation.
(3) Sudden death: sudden death is usually associated with acute occlusion of the left main trunk, and catheterization should be avoided to avoid embedding or damaging
the left main trunk, and in the event of such an event, urgent revascularization should be performed in conjunction with cardiopulmonary resuscitation.
(4) Myocardial infarction: myocardial infarction is mainly due to thrombus or plaque dislodgement into the coronary artery or catheter damage to the coronary
vein, blocking the larger coronary arteries or branches. It can also occur in patients with severely narrowed coronary arteries.
According to the different vessels of obstruction and clinical manifestations, conservative or urgent dish-tube reconstruction treatment is considered.
(5) Embolism: air embolism, thromboembolism, or plaque dislodgement embolism. According to the degree and part of embolism
different, its consequences have differences, the most serious embolism is cerebral artery embolism and coronary artery embolism. In order to prevent their occurrence
, attention should be paid to exhaust all air bubbles in the catheter and at the triple tee and connector; the operation should be as gentle as possible, in strict
accordance with the norms, and high-risk patients should be adequately anticoagulated. Once it occurs, it can be handled accordingly according to the specific situation.
(6) Coronary artery entrapment, more likely to occur in the right coronary artery.
(7) Coronary artery spasm.
(8) Catheter kinking and catheter and guidewire breakage: avoid excessive rotation and pushing of the catheter, to prevent catheter kinking the catheter should be
pushed under X-ray fluoroscopy. When the catheter or guidewire breaks, take appropriate measures according to the specific situation to minimize the damage caused.
(9) Myocardial perforation: the procedure should be terminated immediately. If there is cardiac tamponade, perform pericardiocentesis to draw fluid or pericardial drainage
and closely observe the blood pressure and cardiac shadow changes. If the breach is large and bleeding is not stopping, urgent surgical repair should be performed.
(10) Complications related to contrast media such as allergic reactions, heart failure and contrast nephropathy: try to use non-
ionic contrast media and minimize the amount of contrast media. Benadryl is given in cases of contrast allergy, and those with severe
allergic reactions should also be treated with epinephrine, H2-receptor antagonists such as cimetidine, hormones such as dexamethasone or hydro
cortisone, and respiratory-circulatory support if necessary. For patients at high risk of allergy, antiallergic medications
are given preoperatively (glucocorticoids, benadryl, etc.), rehydration is given as appropriate for renal insufficiency, and diuretics may be given for pulmonary edema and renal failure
.
(11) Complications associated with vascular puncture: bleeding, hematoma, infection, and thrombosis. One should be familiar with the localized decolonization
dissecting structure of the puncture, correctly selecting the puncture site, trying to avoid vascular injury during puncture, and paying attention to the antiseptic
toxicity of the puncture site and aseptic technical operation.