介入手术与解剖

nullEndovascular & Neurovascular Basic Training-Anatomy & ClinicEndovascular & Neurovascular Basic Training-Anatomy & ClinicZhengZhiguo介入放射学发展介入放射学发展古埃及人: 芦苇管扩张尿道 1904 Dawbon: 颜面血肿供血动脉栓塞治疗 1929 Forsmann: 自体右心导管插管 1953 Seldinger: 经皮血管穿刺技术 1964 Dotter, Judkin: 经皮同轴导管血管成形技术 1967 Margulis: 提出Interventional Radiology 1976 Wallace: 系统解释并应用我国介入放射学发展我国介入放射学发展80年代: 刘玉清,刘子江,林贵,陈星荣,李树新 86年: 山东潍坊首届全国介入放射学会议 90年: 卫生部决定将一部分有条件的放射科改为临床科室,称介入放射科 97年: 卫生部和SDA发出“介入性诊疗技术及相关器械的应用和研究”的专题招标, 并列为“九五”攻关计划 目前: “百花齐放, 百家争鸣” 介入放射学概念和范畴介入放射学概念和范畴基本概念 临床范围 诊疗技术 诊疗技术特点介入放射学基本概念介入放射学基本概念介入器材和学: 介入治疗学: 在医学影响设备的引导下,结合临床治疗学原理,通过导管等器材对各种病变进行治疗的一系列治疗技术 介入诊断学: 以影像诊断学和临床诊断学为基础,在医学影像设备引导下,利用简单器材获得病理学,细胞学,生理生化学,细菌学和影像资料的一系列诊断方法临床范围临床范围肿瘤的介入诊疗学 非肿瘤病变的介入诊疗学 心脏及大血管病的介入诊疗学 神经系统疾病的介入诊疗学诊疗技术诊疗技术血管性介入技术 非血管性介入治疗技术血管性治疗技术血管性治疗技术Seldinger技术 选择性和超选择性血管插管技术 经导管血管栓塞术 经导管局部药物灌注术 经导管腔内血管成形术 经皮血管内支架置放术 经颈静脉肝内门腔分流术血管性治疗技术血管性治疗技术经皮血管内异物和血栓取出术 选择性血样本采集术 经皮血管内导管药盒系统植入术 心血管瓣膜成形术 射频消融术 选择性血管造影术和药物性血管造影术非血管介入技术非血管介入技术经皮针吸活检术 经皮局部药物灌注术 经皮穿刺内,外引流术 经皮椎间盘切割术 内支架放置术 输卵管再通术 肺大泡固化术非血管介入技术非血管介入技术腹水-静脉转流术 脑积水-腹腔或静脉转流术 经皮胃造瘘术 电化学治疗术 结石处理技术 “T”型管置换术介入技术特点介入技术特点微创性 可重复性强 定位准确 疗效高,见效快 并发症发生率低 多种技术的联系应用简便易行常用介入诊疗技术常用介入诊疗技术超选择性血管插管技术 经导管动脉内药物灌注术 动脉内化疗术 动脉内其他药物灌注术 经导管动脉栓塞术 经皮腔内血管形成术 经皮血管内导管药盒系统植入术 经皮左锁骨下动脉导管药盒系统植入术 经皮肝门静脉导管药盒系统植入术 经颈静脉肝内门体支架分流术 经皮内外引流术 经皮肝胆道内外引流术 经皮肾盂内外引流术 脓肿囊肿引流术常用介入诊疗技术常用介入诊疗技术内支架植入术 胆道内支架(涵管)置入术 食管内支架置入术 血管内支架置入术 经皮活检术 经皮局部药物注射术 肿瘤内药物注射术 经皮腹腔神经丛阻滞术 经皮腹水-静脉转流术 经皮穿刺胃造瘘术 恶性肿瘤的电化学治疗超选择性血管插管技术超选择性血管插管技术定义: 指在经皮选择性血管插管技术基础上将导管插至2级以上分支的技术(胸,腹主动脉发出的的动脉主枝为一级分支) 适应症: 各种病变的动脉造影,动脉内化疗灌注和动脉栓塞术均应采用本技术,特别是肝动脉亚段栓塞术 禁忌症: 插入动脉直径小于导管直径或已闭塞 并发症: 动脉内膜损伤,动脉痉挛 经导管动脉内药物灌注术经导管动脉内药物灌注术 定义: 导管在肿瘤供养动脉内注入化疗药物,使之达到在与静脉给药者相比时肿瘤局部化疗药物浓度增高,而外周血浆最大药物浓度和浓度时间曲线下面积降低的目的,从而使疗效提高,全身副作用减少 经导管动脉内药物灌注术经导管动脉内药物灌注术适应症:脑原发性和转移性肿瘤 颌面部原发性恶性肿瘤 鼻咽癌,舌癌,上颌窦癌,牙龈癌,甲状腺癌 胸部恶性肿瘤 肺癌,食管癌,乳腺癌,局部复发的乳腺癌 腹部恶性肿瘤 肝癌,胃肠道癌,胆道系统癌,胰腺癌,肾癌,多发性腹部转移瘤 盆腔恶性肿瘤 膀胱癌,前列腺癌,直肠癌,卵巢癌,子宫癌,盆腔转移瘤 骨骼和软组织恶性肿瘤 骨肉瘤,尤文氏等骨恶性肿瘤,骨转移瘤,各种如组织恶性肿瘤 经导管动脉内药物灌注术经导管动脉内药物灌注术禁忌症: 严重出血倾向 通过适当治疗难以逆转的肝,肾功能障碍 严重恶液质 并发症: 血管狭窄及闭塞 神经损伤 消化道反应经导管动脉栓塞术经导管动脉栓塞术定义: 导管插入靶动脉并注如栓塞剂达到治疗目的 适应症: 各种实体性富血性肿瘤的术前和姑息性治疗, 常IACH合用 配合IACH的血流重分布而栓塞胃十二指肠上动脉或一侧髂内动脉 内科性内脏切除,如脾大和脾功能抗进,肾性高血压,大量蛋白尿的栓塞治疗 各种动静脉畸形(A-V-M),外伤性动静脉瘘 难以控制的小动脉出血 经导管动脉栓塞术经导管动脉栓塞术禁忌症: 不能超选择性插入靶动脉或靶动脉有重要器官附属支者 栓塞后可能造成某重要器官衰竭者 体质弱预计难以承受术后反应着 并发症: 误栓 栓塞后并发症经皮腔内血管成形术经皮腔内血管成形术定义: 血管狭窄可有多种病因引起,如血管肌纤维结构不良,血管蹼或发育畸形(不加综合征）,自体免疫异常(多发性动脉炎),动脉粥样硬化,手术放疗后,后果是在动脉系统为器官缺血,萎缩,功能障碍,并引发系统性改变,如肾性高血压;在静脉系统则造成回流障碍,并继发一系列改变。 PTA是指经皮穿刺置入球囊导管等器材,对狭窄段血管进行扩张的一系列技术,原理是通过球囊扩张对狭窄血管内膜,中膜的撕裂,使其管腔扩大,扩大的管径由血压维持,损伤的由血小板,纤维沉积,后由血管内皮覆盖修复,目前PTA技术常与血管内支架术配合治疗血管狭窄。 经皮腔内血管成形术经皮腔内血管成形术适应症: 原则上影响器官功能的血管狭窄(闭塞)均为适应症 禁忌症: 严重出血倾向 缺血器官功能以丧失 大动脉炎活动期 导丝,导管未能插过血管狭窄(闭塞)段经皮腔内血管成形术经皮腔内血管成形术并发症: 普通并发症参见超选择插管术 由于术中应用较大肝素,穿刺部位易发生血肿 血管急性闭塞 血管损伤经颈静脉肝内门体支架分流术经颈静脉肝内门体支架分流术定义: TIPSS集穿刺,PTA,内支架等介入技术为一体成为当今介入放射学发展高峰之一 适应症: 肝硬化门静脉高压引起消化道出血,经内科内窥镜硬化治疗仍反复出血者 保守治疗不能止血者,可急诊TIPSS 上述患者为肝移植等代供体期间发生消化道出血和顽固性腹水 肝硬化门静脉高压引起顽固性腹水可选用TIPSS 经颈静脉肝内门体支架分流术经颈静脉肝内门体支架分流术禁忌症: 肝肾功能衰竭者 反复发生肝性脑病者 肝外形门静脉高压者 心功能不全 肝癌位于穿刺通道 并发症: 与操作有关的出血 术后并发症 慢性肝功能衰竭,肝性脑病,通道再狭窄及闭塞胆道内支架(涵管)置入术胆道内支架(涵管)置入术定义: 与PTCD比较优点为永久性内引流 适应症: 由胆道及其周围组织恶性肿瘤引起的阻塞性黄疸 由结石,炎症和手术引起的胆道狭窄并阻塞性黄疸 先天性胆管囊肿和化脓性胆管炎 胆道内支架(涵管)置入术胆道内支架(涵管)置入术禁忌症: 明显出血倾向 大量腹水 肝功能衰竭者 严重的胆道感染 并发症: 假道形成 胰腺炎 支架移位 通道再狭窄及闭塞血管内支架置入术血管内支架置入术定义: 应用于动静脉系统的局限性狭窄和闭塞,重建血管通道并纠正血流动力学异常,带膜支架可用于治疗假性动脉瘤 适应症: 各种原因引起的血管狭窄和闭塞 建立血流分流通道,如TIPSS血管内支架置入术血管内支架置入术禁忌症: 不适于血管造影者 导丝不能通过狭窄部位 通过PTA能达到预定的疗效 并发症: 支架移位 支架逸走nullLeft gastric artery 胃左动脉Splenic artery 脾动脉Coeliac trunk 腹腔干Superior mesenteric artery 肠系膜上动脉Renal Artery 肾动脉Lumbar Artery 腰动脉Inferior Mesenteric Artery 肠系膜下动脉 Aortic bifurcation 大动脉分支Caudal Artery骶尾动脉Common iliac Artery 髂总动脉Internal Iliac Artery 髂内动脉External Iliac Artery髂外动脉Inguinal ligament 腹股沟韧带Common hepatic artery 肝总动脉ABDOMINAL AORTA 腹部大动脉nullSUPRA-AORTIC TRUNK         1-Aortic arch 主动脉弓 2-brachiocephalic trunk 头臂干 3-Common carotid artery 颈总动脉 4-Subclavian arteries 锁骨下动脉 5-Vertebral arteries 椎动脉 6-External carotid arteries 颈外动脉 7-Internal carotid arteries 颈内动脉     nullScarpa triangle 腹股沟三角 Right common femoral 右股总动脉 Right deep femoral / Profunda 右股深动脉,静脉 Superficial femoral artery 股浅动脉 Popliteal artery 腘动脉 Anterior tibial artery 颈前动脉 Peroneal artery 腓骨动脉 Posterior tibial artery 颈后动脉 Dorsalis Pedis artery 足背动脉 ARTERIAL SUPPLY OF LOWER LIMBS   nullAortic arch 主动脉弓Left Pulmonary artery 肺左动脉Left atrium 左心房Left Pulmonary veins 肺左静脉Mitral valve 二尖瓣Left ventricle 左心室Aortic valve 主动脉瓣Tricuspid valve 三尖瓣Descending Aorta 降主动脉Right ventricle 右心室Inferior vena cava 下腔静脉Right atrium 右心房Pulmonary valve 肺动脉瓣Right brachiocephalic vein 右头臂静脉Anatomy of the Heart 心脏解剖 nullLeft brachiocephalic 左头臂静脉Left subclavian 左锁骨下静脉Left cephalic Left axillarySplenic 脾静脉Left renal 左肾静脉Inferior mesenteric 肠系膜下静脉Left external iliac 左髂外静脉Left digitals Left palmar venous archLeft femoral Left poplitealLeft posterior tibialLeft peronealLeft anterior tibialLeft dorsal venous archRight small saphenousRight great saphenousRight common iliacInferior vena cavaSuperior mesentericPortal veinRight hepaticSuperior vena cavaRight external jugularRight internal jugularnullVascular Anatomy and Angiograms 血管解剖和造影How are arteries constructed How are arteries constructed The Artery WallThe Artery WallThe circulatory systemThe circulatory systemThe CirculationThe CirculationHeart Arteries Arterioles Capillaries Venules VeinsThe HeartThe HeartThe AortaThe AortaArterial systemThe heart and the big vesselsThe heart and the big vesselsThe aortic archThe aortic archThe Thoracic AortogramThe Thoracic AortogramThe AortaThe AortaArterial systemThe AortaThe AortaArterial systemAbdominal AortogramAbdominal AortogramThe AortaThe AortaVenous systemThe Carotid arteriesThe Carotid arteriesThe Carotid arteriesThe Carotid arteriesThe Carotid arteriesThe Carotid arteriesThe Renal ArteryThe Renal ArteryThe Renal ArteriogramThe Renal ArteriogramThe KidneyThe KidneyThe Kidneys (II)The Kidneys (II)The AbdomenThe AbdomenThe Celiac TrunkThe Celiac TrunkHepatic arteryLeft gastric arterySplenic arteryCoeliac trunkThe Celiac AortogramThe Celiac AortogramThe Celiac TrunkThe Celiac TrunkThe SMAThe SMAThe SMAThe SMAThe IMAThe IMALower extremitiesLower extremitiesArterial systemIliac ArteriesIliac ArteriesInternal Iliac ArteriesInternal Iliac ArteriesPelvis arteriesPelvis arteriesThe Femoral ArteryThe Femoral ArteryThe Femoral ArteryThe Femoral ArteryThe Popliteal ArteryThe Popliteal ArteryBelow-The-KneeBelow-The-KneeBelow-The-KneeBelow-The-KneeLower extremitiesLower extremitiesVenous systemUpper extremitiesUpper extremitiesArterial systemUpper extremitiesUpper extremitiesArterial systemUpper extremitiesUpper extremitiesArterial systemUpper extremitiesUpper extremitiesArterial systemUpper extremitiesUpper extremitiesVenous systemAtherosclerosisAtherosclerosisAbnormalities:Abnormalities:Abdominal Aortic AneurysmAbnormalities:Abnormalities:Collateral CirculationnullCollateral CirculationAbnormalities:Abnormalities:Abnormalities:DissectionAbnormalities:Abnormalities:Fibro Muscular DysplasiaAbnormalities:Abnormalities:AneurysmAbnormalities:Abnormalities:ThrombosisAbnormalities:Abnormalities:OcclusionAbnormalities:Abnormalities:Occlusion Post StentAbnormalities:Abnormalities:Atherosclerosis StenosisAbnormalities:Abnormalities:Plaque StenosisAbnormalities:Abnormalities:Eccentric Atherosclerotic plaquesAbnormalities:Abnormalities:Atherosclerosis in SFAPORTAL HYPERTENSIONPORTAL HYPERTENSIONPortal HypertensionPortal HypertensionCauses Alcoholism Hepatitis Effects Sclerosis of parenchymia reducing blood exchange between portal system and hepatic vein. Provocates gastro-intestinal bleedings.Cirrhotic liverCirrhotic liverPortal HypertensionPortal HypertensionPortal HypertensionPortal HypertensionPortal vein is mainly supplied by gastro-intestinal blood.Portal HypertensionPortal HypertensionVarices of oesophagusVarices of oesophagusVarices of the IntestineVarices of the IntestineDuodenumSigmoidPortal HypertensionPortal HypertensionHow can we treat ? Transjugular Intra-hepatic Porto-systemic Shunt: TIPS (Palliative treatment). It reduces portal pressure. By creating an artificial tract between the portal vein and the hepatic vein.Portal HypertensionPortal HypertensionHow can we treat ? Powerflex P3 Palmaz and Palmaz GenesisnullClinical symptoms: - Icterus (yellow coloration) ± pruritis (itching). - Impact on general health (fatigue). Diagnostic - Biological test of liver functions - Echography, scanner - MRI of biliary tree Etiology - Benignant: Cholangitis, pancreatitis - Malignant : Cholangiocarcinoma, pancreatic or liver tumour.BILIARY TREE STENOSISWhen symptoms develop…When symptoms develop…Jaundice (itching) Weight loss Fatigue Generally due to advanced stageDestruction of Red blood cellsDestruction of Red blood cellsDead RBC are engulfed by Macrophages (Phagocytes). Resulting components are absorbed by the bone marrow (Iron + Amino acids) or transported to the liver (Bilirubin) and excreted in the bile. Destruction of Red blood cellsDestruction of Red blood cellsBilirubin gives the brown coloration to feces and the yellow color to urine. nullClinical: -Yellow coloration of skin and mucosa -Darkened urines and whiter feces Biology: - Increase of bilirubin, alcalin phosphatasis and of gamma GT Mecanism - intra-hepatic cholestasis : hepatitis - extra-hepatic cholestasis : obstacle in Biliary treeICTERUS / JAUNDICEnullLocation of the Biliary tree in our BodyBiliary tree anatomyBiliary tree anatomyNormal bile ductNormal bile ductBenignant diseases Benignant diseases Cholangitis Pancreatitis 1-6 per 100 000 hab in US Mainly men between 40-70 years old Treatments: Drug: Ursodeoxycholic acid Surgery or Endovascular Liver transplantWhat is Primary Sclerosing Cholangitis ?What is Primary Sclerosing Cholangitis ?A chronic fibrosing inflammatory process Results in: Obliteration of biliary tree Biliary tree cirrhosis Stricture are located both in intrahepatic and extrahepatic ductsIntrahepatic and extrahepatic strictures secondary to cholangitisIntrahepatic and extrahepatic strictures secondary to cholangitisCausesCausesNot really known But some theories about: Genetic abnormalities Viral infection Bacteria in Portal vein Etc…SymptomsSymptomsMost of the patients are asymptomatic Detected during abnormal biochemical testsBiliary obstruction secondary to PancreatitisBiliary obstruction secondary to PancreatitisMalignant diseases Malignant diseases Cholangiocarcinoma Liver tumour Pancreatic tumour Treatments: Drug: chemiotherapy Surgery or Endovascular Liver transplantMalignant diseaseMalignant diseaseHave a compressive effect on the biliary tree. Generally needs to be stented. Endovascular = Palliative treatment.Cholangiocarcinoma of common bile ductCholangiocarcinoma of common bile ductCholangiocarcinomaCholangiocarcinomaEndovascular interventionsEndovascular interventionsDiagnostic Drainage Balloon dilation Plastic or metal stenting: ERCP approach Percutaneous transhepatic approachERCPERCPThe endoscopic retrograde CholangiopancreatographyEndoscopic Retrograde CholangiopancreatographyEndoscopic Retrograde CholangiopancreatographyEndoscopeEndoscopePancreatitis: Sphincterotomy and stent placement (ERCP)Pancreatitis: Sphincterotomy and stent placement (ERCP)PTA / StentingPTA / StentingPTA or stentingPTA or stentingPercutaneous Transhepatic ApproachPercutaneous Transhepatic ApproachPercutaneous Biliary drainage Percutaneous Biliary drainage Pancreatatis: Plastic stent placementPancreatatis: Plastic stent placementPercutaneous transphepathic cholangiographyPercutaneous transphepathic cholangiographyPercutaneous therapyPercutaneous therapynullI: Endoscopy (GE) II: Endoscopic stent (GE) III: Radiology IV: Abstention ?Who is treating biliary stenosis ? Plastic stents: polyethylene or teflon (10-11 F) Plastic stents: polyethylene or teflon (10-11 F) Advantages Good efficacy for low life expectancy patients (<6 months). Low morbidity Low cost Short hospital stay Inconvenients Obstruction risk (70% at 6 months) Needs to be replaced frequentlyMetal stents 4 to 9 cm long and 8 to 10 mm diameter.(5F-7F) Metal stents 4 to 9 cm long and 8 to 10 mm diameter.(5F-7F) Advantages Good efficacy on patient with life expectancy > 6 months Low morbidity Short hospital stayInconvenients High cost compared to plastic stents