Catheterization of the femoral artery in the celebrity. Arterial access (radiation of the radiation artery). Cathetterization Methodology for Seld

Indications:

Intraartile and intraarterial administration of medicines;

Long-term monitoring of hemodynamics and gas composition of arterial blood;

Arteriography research;

Introduction of an intra-director balloon pump.

Contraindications:

Inflammatory changes or scars in the groin area;

The impossibility of observing the sick bed regime.

1.brush, handle the inguinal area with an antiseptic solution, is degraded by its sterile material.

2. Pulse on the femoral artery per 1- 2 cm below the middle of the tipped ligament.

3.Sesese the skin and subcutaneous tissue along the type of artery.

4. Punctioning needle with a length of 7 cm with a syringe or a needle of the Seldinger Pierce the skin over the artery and promote the needle in the cranial direction at an angle of 45 ° to the skin surface to the pulsating vessel.

5. The prolque of the front wall of the artery in the syringe should seem arterial blood. When using the needle of the cemetery, the blood stream appears from it after removing the Mandrena.

6. If the needle passed into the clearance of the arteries, disconnect the syringe, clamping the cannula of the needle with a finger to prevent excessive bleeding.

7. The needle for the armful blood stream is administered towards the heart metal conductor with a flexible end, holding the needle in the same position. The conductor must undergo an artery with minimal resistance.

8. As soon as the conductor passed, the needle is removed, constantly fixing his position.

9. For example, expand the puncture hole with a sterile scalpel.

10. The central venous catheter leads on the conductor.

11. Explorer and attach the system for washing. Fix the catheter to the skin of silk seams, impose a sterile bandage.

Actions with possible complications:

Punching of femur veins: finger pressed for 10 minutes;

Hematoma: the removal of the catheter, pressing the point of puncture within 15-25 minutes, tight bandage for 30 minutes, bedding, control of the pulse on the arteries of the lower limb;

Thrombosis: Catheter removal, control over the pulse on the arteries of the limb (distal embolism possible).

Canyulation of radial artery

Indications:

Intraarterial blood injection when conducting resuscitation activities;

Long monitoring of hemodynamics and gas composition of arterial blood.

Contraindication:

Occlusion radial artery.

1. But the inner surface of the wrist is treated with antiseptic solution and is deducted with sterile napkins.

2. The distal end of the radial bone palprate the pulse on the radial artery and the skin and subcutaneous fiber are anesthesize.

3.New radiation artery in the longitudinal direction dissect the skin and surface fascia for 2.5 cm.

4. Hellorately isolated by the artery with a curved hemostatic clamp and fed under it silk ligatures - proximal and distal.

5.Distal arteries department ligate, the artery is carefully tightened for the ends of the proximal thread, the front wall is supervised by pointed scissors.

6.The Catheter is introduced into the lumen of the arteries, the proximal ligature is tied.

7. In terms of intraarterial injection of a sterile physiological solution, the wound is shed, apply a aseptic bandage.

Actions with possible complications:

Bleeding: finger pressed, then tight sterile bandage;

Armedi spasm: 2% Papaverin solution locally and 2 ml subcutaneously.

29636 0

1. Indications:
a. The impossibility of catheterization of a subclavian or inner jugular vein for measuring the FLOD or the introduction of inotropic agents.
b. Hemodialysis.
2. Contraindications:
a. Surgical operation in the groin area in history (relative contraindication).
b. The patient must comply with bedding until the catheter is in Vienna.
3. Anesthesia:
1% lidocaine.

4. Equipment:
a. Antiseptic for skin treatment.
b. Sterile gloves and napkins.
c. Needle 25 caliber.
d. Syrins 5 ml (2).
e. Suitable catheters and expander
f. System for transfusion (fastened).
g. Needle for carbonation of 18 caliber (5 cm long).
h. 0.035 J-shaped conductor.
i. Sterile bandages
j. Safety razor
to. Scalpel
l. Suture material (Silk 2-0).

5. Position:
Lying on the back.

6. Technique:
a. Early, make skin treatment with antiseptic solution and sort out the left or right inguinal area with sterile material.
b. Squeeze the pulse on the femoral artery at the point in the center of the imaginary segment between the upper front ileum and the Lona Jim. The femoral vein goes parallel and medially the artery (Fig. 2.10).

Fig. 2.10

c. Enter anesthetic through the needle 25 caliber in the skin and subcutaneous tissue per 1 cm medial and 1 cm distal than the point described above.
d. Plut the pulse on the femoral artery and carefully move it laterally.
e. Attach an 18-ml cable punctural needle to 5 ml syringes, pinched anesthetized skin and, aspiring, promote the needle in the cranial direction at an angle of 45 ° to the surface of the skin parallel to the pulsating artery. The risk with a media approach to Vienna is less compared to lateral (Fig. 2.11 and 2.12).

Fig. 2.11

Fig. 2.12.

f. If the venous blood in the syringe did not appear after the introduction of the needle to a depth of 5 cm, slowly remove the needle, constantly aspiring. If still there is no blood, change the direction of movement of the needle through the same punkey hole cranially and 1-3 cm la-therally, in the direction of the artery.

G. If there is still no back current current, recheck the guidelines and try again at a point located 0.5 cm medial pulse, as described in (e). If this attempt is unsuccessful, stop the procedure.
h. If arterial blood appeared in the syringe, remove the needle and press this place as described below.
i. If you get into the vein, disconnect the syringe and press the hole cannula needles with a finger to prevent an air embolism.

J. Enter the J-shaped conductor through the needle towards the heart, holding it in the same position. The conductor must pass with minimal resistance.
To. If resistance met, remove the conductor, make sure that the needle is in Vienna, aspiring blood into the syringe.

1. As soon as the conductor passed, remove the needle, constantly controlling the position of the conductor.
m. Expand the puncture hole with a sterile scalpel.
n. Enter the extension on the conductor by 3-4 cm, spreading subcutaneous tissues and holding the conductor. It is not recommended to enter an extender deeper, as you can damage the femoral vein.

O. Remove the expander and enter the central venous catheter for a length of 15 cm on the conductor.
R. Remove the conductor, aspi the blood through all the ports of the catheter to confirm its intravenous position, adjust the infusion of a sterile isotonic solution. Fix the catheter to the skin of silk seams. Take a sterile bandage on the skin.
q. The patient must observe the bed mode before the catheter extraction.

7. Complications and their elimination:
but. Punching of the femoral artery / hematoma
. Remove the needle.
. Press your hand for 15-25 minutes, then impose a gulling bandage for another 30 minutes.
. Bed regime at least 4 hours
. Control the pulse on the lower limb.

Chen G., Sola H.E., Lilleos K.D

Artery puncture and veins are a necessary procedure when conducting a diagnostic examination of patients with suspected venous and heart failure, thrombophlebitis and varicose veins. The puncture of the artery makes it possible to assess the nature of blood flow and blood pressure. In addition to the diagnostic purposes, the artery puncture is also carried out if the need for rapid blood flow (blood transfusion) and when the special preparation is introduced to stimulate the work of the heart.

The purpose of the puncture of the artery

The puncture of the artery allows the procedure of angiography, due to which the doctor has the ability to accurately assess the work of the circulatory system. The procedure is used in the diagnosis of diseases such as atherosclerosis, thrombosis, embolism, aneurysms and vascular injury. The artery puncture is an important step in conducting minimally invasive interventions on blood vessels, as it allows the necessary procedures under constant visual control.

Thanks to the procedure for the control of the artery, the procedure for the diagnosis of many diseases of the heart and domestic organs, as well as the process of thrombosis and the subsequent migration of thromboms by arteries, was significantly simplified. An indication of the artery puncture is also the need for clinical arterial blood studies and the need for constant blood pressure monitoring, for which a special catheter is introduced after puncture in the artery. The artery puncture is not carried out in the case of fractures of ribs and clavicle, with inflammatory processes and exacerbation of a number of chronic diseases.

Procole technique

Most often artery puncture It is conducted in the elbow area. Before carrying out an artery puncture, the doctor must make sure that the elbow artery function normally and provides blood circulation, for this, the doctor conducts the procedure for transferring radiation and elbow artery as a result of which the patient's brush is palenet. When the hand load (compression and relaxation of the brush), the color of the skin of the skin from the deathly pale to gray is marked. After removing the squeezing dressing, the normal color of the skin is restored after a few seconds, indicating normal blood circulation.

The procedure for the puncture of the artery is carried out under the action of local anesthesia and processing the place of puncture by antiseptic and antibacterial drugs. Under the hand of the patient for convenience, the roller is put on, the artery is fixed with his fingers and enter the needle, while the angle of the needle tilting is 45-50⁰. The introduction of the needle at a right angle allows you to minimize damage to the artery, but not everyone can perform such a procedure. Experienced medical workers easily determine the approach to the artery on the pulsation, which is transmitted through the needle, which avoids such negative consequences as injury to both the walls of the artery and the formation of the hematoma. The appearance of blood scarlet is evidenced about the artery puncture.

In the case of puncture of the femoral artery, the procedure is similar to the crossing of the elbow vein, the difference is only the size of the needle used. For the convenience of puncture of the femoral artery, the needle is planted for a syringe. After the necessary diagnostic and therapeutic manipulations of the needle removes from the artery. If necessary, it remains in the arteries and a special catheter is connected to it through which further procedures are performed.

Complication of puncture

The main consequence of the artery puncture is a double puncture, the formation of hematomas and injury of nerve endings. In case of chronic diseases of the cardiovascular system, the complex and serious consequence of puncture can be the formation of thromboms. In rare cases, such complications are noted as an allergic reaction and bleeding in the field of puncture. Avoiding the negative effects of the artery puncture will help the observance of rest, as well as strict adherence and fulfillment of all the recommendations of the doctor. After the puncture of the femoral artery, the patient recommended bed and wearing the gagging bandage, which is usually removed the next day after the procedure. In our clinic, you can get qualified assistance in all types of cardiovascular diseases, go through the necessary examination and treatment.

The easiest and fastest way to gain access to the introduction of medicines is to conduct catheterization. Mostly use large and central vessels, such as the inner upper hollow or jugular vein. If there is no access to them, then alternative options are found.

For what is carried out

The femoral vein is in the groin area and is one of the major highways carrying out blood outflow from the lower human limbs.

The catheterization of the femoral vein saves life, as it is in an affordable place, and in 95% of cases of manipulation are successful.

Indications for this procedure are:

the inability to introduce drugs into the jugular, the upper hollow vein;
hemodialysis;
conducting resuscitation actions;
diagnostics of vessels (angiography);
the need for infusion infusion;
pacemaker;
low pressure with unstable hemodynamics.

Preparation for the procedure

For puncture of the femoral veins of the patient laid on the couch in the position on the back and ask to pull out and slightly dilute the legs. Under the flange put a rubber roller or pillow. The skin surface is treated with aseptic solution if the hair is swung, and the injection site is limited to sterile material. Before using the needle, Venu is found and tested with pulsation.

The equipment includes:

sterile gloves, bandages, napkins;
anesthetic;
needles for catheterization 25 caliber, syringes;
needle 18 sizes;
catheter, flexible conductor, expander;
scalpel, suture material.

Objects for catheterization must be sterile and be at hand of a doctor or nurses.

Technique of conducting, the introduction of the catheter for the Seldgermer

Seldinger is a Swedish radiologist, which in 1953 developed a method of catheterization of large vessels using conductor and needles. The puncture of the femoral artery on its method is carried out to today:

The gap between the LONA joint and the front of the unesia of the ilium is conventionally divided into three parts. Hip artery is located in the junction of the medial and middle third of this site. The vessel should be moved away laterally, as Vienna goes parallel.
The place of puncture is drunk on both sides, making subcutaneous anesthesia by lidocaine or other painkillers.
The needle is introduced at an angle of 45 degrees at the venue pulsation site in the region of the groove bundle.
When the blood of a dark cherry color appears, the puncture needle is conducted along the vessel for 2 mm. If the blood does not appear, you must repeat the procedure first.
The needle holds the left hand motionless. A flexible conductor is introduced into her cannula and promote it through a slice in Vienna. Promotion to the vessel should not interfere, with resistance it is necessary to slightly turn the tool.
After successfully administration, the needle is removed by pressing the injection site to avoid hematoma.
A dilator is put on the conductor, pre-examined the point of administration to the scalpel, and introduce it to the vessel.
The expander is removed and the catheter is introduced to a depth of 5 cm.
After successfully replacing the conductor, the catheter is attached to the syringe and pull the piston on themselves. If blood flows, the infusion is connected with isotonic solution and fixed. Free passage of the drug suggests that the procedure has passed correctly.
After manipulation, the patient is prescribed bed regime.

Installing the catheter under ECG control

Using this method reduces the amount of postmanipulation complications and facilitates monitoring the state of the procedurewhose sequence is as follows:

The catheter is clean with isotonic solution using a flexible conductor. The needle is introduced through the plug, and the tube is filled with NaCl solution.
To the cannula, the needles summarize "V" or fasten it using a clamp. The device includes the "Breast Dead" mode. Another way proposed to connect the wire of the right hand to the electrode and turn on the opening number 2 on the cardiograph.
When the end of the catheter is located in the right ventricle of the heart, then on the monitor, the QRS complex becomes higher than when norm. Reduce the complex by adjusting and pulling the catheter. High teeth P indicates the location of the apparatus in atrium. Further direction for a length of 1 cm. Leads to the alignment of the teeth in the norm and the correct location of the catheter in the field Vienna.
After the manipulation performed, the tube is laid or fixed with a bandage.

Possible complications

When conducting catheterization, it is not always possible to avoid complications:

The most frequent unpleasant consequence is the puncture of the rear wall of the veins and, as a result, the formation of hematoma. There are cases when it is necessary to make an additional incision or puncture a needle to remove the blood sticking between the fabrics. The patient is prescribed bedding, tight binting, a warm compress in the thigh area.
The formation of thrombus in the femoral vein has a high risk of complications after the procedure. In this case, the leg is put on an exalted surface to reduce swelling. Prescribed drugs that dilute blood and contributing to the resorption of thrombus.
Posnigal phlebitis is an inflammatory process on the vein wall. The overall condition of the patient is worsening, the temperature of up to 39 degrees appears, Vienna has a kind of harness, tissue around it swell, become hot. The patient is carried out antibacterial therapy and treatment with non-steroidal drugs.
Air embolism - air enter the venous vessel through the needle. The outcome of this complication may be a sudden death. The symptoms of embolism becomes weak, deterioration of the overall state, loss of consciousness or convulsions. The patient is transferred to intensive care and connect to the pulmonary breathing apparatus. With timely assistance, the condition of a person comes to normal.
Infiltration - the introduction of the drug is not a venous vessel, but under the skin. May lead to necrosis of tissues and surgical interference. Symptoms serve swelling and redness of the skin. When infiltrate occurs, it is necessary to make resorpting compresses and remove the needle, stopping the admission of the medicinal substance.

Modern medicine does not stand still and is constantly developing to save as much lives as possible. It is not always possible to assist on time, but with the introduction of the latest technologies, mortality and complications after the complicated manipulation decreases.

If there is no access to them, then alternative options are found.

For what is carried out

The femoral vein is in the groin area and is one of the major highways carrying out blood outflow from the lower human limbs.

The catheterization of the femoral vein saves life, as it is in an affordable place, and in 95% of cases of manipulation are successful.

Indications for this procedure are:

the inability to introduce drugs into the jugular, the upper hollow vein;
hemodialysis;
conducting resuscitation actions;
diagnostics of vessels (angiography);
the need for infusion infusion;
pacemaker;
low pressure with unstable hemodynamics.

Preparation for the procedure

The equipment includes:

sterile gloves, bandages, napkins;
anesthetic;
needles for catheterization 25 caliber, syringes;
needle 18 sizes;
catheter, flexible conductor, expander;
scalpel, suture material.

Objects for catheterization must be sterile and be at hand of a doctor or nurses.

Technique of conducting, the introduction of the catheter for the Seldgermer

Seldinger is a Swedish radiologist, which in 1953 developed a method of catheterization of large vessels using conductor and needles. The puncture of the femoral artery on its method is carried out to today:

The gap between the LONA joint and the front of the unesia of the ilium is conventionally divided into three parts. Hip artery is located in the junction of the medial and middle third of this site. The vessel should be moved away laterally, as Vienna goes parallel.
The place of puncture is drunk on both sides, making subcutaneous anesthesia by lidocaine or other painkillers.
The needle is introduced at an angle of 45 degrees at the venue pulsation site in the region of the groove bundle.
When the blood of a dark cherry color appears, the puncture needle is conducted along the vessel for 2 mm. If the blood does not appear, you must repeat the procedure first.
The needle holds the left hand motionless. A flexible conductor is introduced into her cannula and promote it through a slice in Vienna. Promotion to the vessel should not interfere, with resistance it is necessary to slightly turn the tool.
After successfully administration, the needle is removed by pressing the injection site to avoid hematoma.
A dilator is put on the conductor, pre-examined the point of administration to the scalpel, and introduce it to the vessel.
The expander is removed and the catheter is introduced to a depth of 5 cm.
After successfully replacing the conductor, the catheter is attached to the syringe and pull the piston on themselves. If blood flows, the infusion is connected with isotonic solution and fixed. Free passage of the drug suggests that the procedure has passed correctly.
After manipulation, the patient is prescribed bed regime.

Installing the catheter under ECG control

The use of this method reduces the number of postmanipulation complications and facilitates monitoring the state of the procedure carried out, the sequence of which is as follows:

The catheter is clean with isotonic solution using a flexible conductor. The needle is introduced through the plug, and the tube is filled with NaCl solution.
To the cannula, the needles summarize "V" or fasten it using a clamp. The device includes the "Breast Dead" mode. Another way proposed to connect the wire of the right hand to the electrode and turn on the opening number 2 on the cardiograph.
When the end of the catheter is located in the right ventricle of the heart, then on the monitor, the QRS complex becomes higher than when norm. Reduce the complex by adjusting and pulling the catheter. High teeth P indicates the location of the apparatus in atrium. Further direction for a length of 1 cm. Leads to the alignment of the teeth in the norm and the correct location of the catheter in the field Vienna.
After the manipulation performed, the tube is laid or fixed with a bandage.

Possible complications

When conducting catheterization, it is not always possible to avoid complications:

The most frequent unpleasant consequence is the puncture of the rear wall of the veins and, as a result, the formation of hematoma. There are cases when it is necessary to make an additional incision or puncture a needle to remove the blood sticking between the fabrics. The patient is prescribed bedding, tight binting, a warm compress in the thigh area.
The formation of thrombus in the femoral vein has a high risk of complications after the procedure. In this case, the leg is put on an exalted surface to reduce swelling. Prescribed drugs that dilute blood and contributing to the resorption of thrombus.
Posnigal phlebitis is an inflammatory process on the vein wall. The overall condition of the patient is worsening, the temperature of up to 39 degrees appears, Vienna has a kind of harness, tissue around it swell, become hot. The patient is carried out antibacterial therapy and treatment with non-steroidal drugs.
Air embolism - air enter the venous vessel through the needle. The outcome of this complication may be a sudden death. The symptoms of embolism becomes weak, deterioration of the overall state, loss of consciousness or convulsions. The patient is transferred to intensive care and connect to the pulmonary breathing apparatus. With timely assistance, the condition of a person comes to normal.
Infiltration - the introduction of the drug is not a venous vessel, but under the skin. May lead to necrosis of tissues and surgical interference. Symptoms serve swelling and redness of the skin. When infiltrate occurs, it is necessary to make resorpting compresses and remove the needle, stopping the admission of the medicinal substance.

Angiography on the celebrity - method of diagnostics of vessels

Under angiography with implies a x-ray contrast study of blood vessels. This technique is used in computed tomography, radioscopy and radiography, the main goal is to evaluate the oral blood flow, the state of the vessels, as well as the length of the pathological process.

This study should be carried out only in special X-ray-angiographic offices based on specialized medical institutions, which have modern angiographic equipment, as well as the corresponding computer equipment that can register and process the obtained images.

Agiography is one of the most accurate medical research.

This diagnostic method can be used in the diagnosis of ischemic heart disease, renal failure, and to detect various kinds of brain circulation disorders.

Types of AorTographs

In order to contrast the aorta and its branches, in the case of the preservation of the femoral artery, the method of percutaneous catheterization of the aorta (angiography according to the Selderger) is most often used, with the aim of visual differentiation of the abdominal aorta, the transcilum puncture of the aorta is used.

It is important! The technique implies the introduction of an iodine-containing water-soluble contrast agent by direct puncture of the vessel, most often through the catheter, which is introduced into the femoral artery.

Cathetterization Methodology for Seld

Cressing catheterization of the femoral artery according to the Selderger is performed using a special set of tools, which includes:

puncture needle;
dilator;
inverter;
metal conductor with a soft end;
catheter (size 4-5 f via FRENCH).

Using the needle, a femoral artery puncture is performed for a metal conductor in the form of a string. The needle is then removed, and through the conductor in the lumen of the artery, a special catheter is introduced - this is called aortography.

Due to the manipulation soreness, the patient in consciousness needs infiltration anesthesia using a lidocaine and novocaine solution.

It is important! Cressing catheterization of the aorta in the Seldger is also possible through the axillary and shoulder artery. Cutter through the data of the artery is more often carried out in cases where there is impassability of the femoral arteries.

Angiography according to Selderger in many senses is considered universal, which is why it is used most often.

Translumal puncture of aorta

In order to conduct visual differentiation of the abdominal aorta or the arteries of the lower extremities, for example, when they were damaged by aorto-arteultite or atherosclerosis, preference is given to this method as direct transcilum puncture of the aorta. Points up aorta by means of a special needle from the back.

If it is necessary to obtain contrasting the branches of the abdominal aorta, the high transvammal aortography with the jacket of the aorta is carried out at the level of 12 breast vertebra. If the problem includes the process of contrasting the bifurcation of the artery of the lower extremities or the abdominal aorta, the transcilia puncture of the aorta is carried out at the level of the lower edge of the 2 lumbar vertebra.

During this transciliation puncture, it is very important to take a partially carefully regarding the research methodology, in particular, two-stage needle removal is carried out: first it must be removed from the aorta and only after a few minutes - from the pararaortion space. Thanks to this, it is possible to avoid and prevent the process of formation of large pararaortion hematomas.

It is important! Such techniques such as the transciliation of the aorta and angiography on the Seldger are the most widely used procedures for contrasting arteries, aortic and its branches, it allows you to obtain an image of almost any area of \u200b\u200bthe arterial bed.

The use of these techniques in the conditions of special medical institutions allows you to achieve minimal risk of complications and at the same time is an affordable and highly informative diagnostic method.

Seldinger Method (S. Seldinger; puncture catheterization arteries) - The introduction of a special catheter into the blood vessel by its percutaneous puncture with a diagnostic or therapeutic purpose. Proposed by the Seldger in 1953 for puncture of arteries and selective arteriography. Subsequently, S. m. Began to use for both the vein puncture (see the venue catheterization).

S. m. Apply for the purpose of catheterization and contrasting study of the atria and ventricles of the heart, aortic and its branches, the introduction of dyes, radiopharmaceuticals, drugs, donor blood and blood substitutes in arterial bed, as well as if necessary, a multiple arterial blood study.

Contraindications are the same as for the catheterization of the heart (see).

Research is carried out in the X-ray Operational (see Operational Block) using special tools included in the celebringer set, - Troacara, Conditions of the conductor, polyethylene catheter, etc. Instead of a polyethylene catheter, you can apply the edman catheter - X-ray-contrast elastic plastic tube red, green or yellow Depending on the diameter. The length and diameter of the catheter is selected based on the tasks of the study. The inner sharp end of the catheter is tightly adjusted to the outer diameter of the conductor, and the outdoor to the adapter. The adapter is connected to a syringe or measuring instrument.

Usually S. m. Apply for selective arteriography, for which they produce percutaneous puncture more often than the right femoral artery. The patient is laid on the back on a special table for catheterization of the heart and somewhat discharged in the direction of his right leg. Pre-shave the right-hand inguinal region disinfect, and then isolate with sterile sheets. With the left hand, they prove the right femoral artery at once below the groove bunch and fix it with the index and middle fingers. Anesthesia of the skin and subcutaneous fiber is produced by 2% P-r-novocaine with a thin needle so as not to lose the feeling of the pulsation of the artery. The scalpel is cut off the skin over the artery and the trocar is introduced, the tip of the swarm is trying to grope pulsating artery. Tilting the outdoor end of the trocar to the skin of the thigh at an angle of 45 °, the front wall of the artery is pierced with a rapid short movement (Fig., A). Then the trocark is tilted even more than the hip, remove the mandren from it and insert the conductor to meet the jet of the blood curb, the soft end of the k-pogo is promoted into the lumen of the artery under the inguinal bundle by 5 cm (Fig., B). Through the skin, the guide in the left hand is recorded by the conductor in the arteries, and the trocar is removed (Fig., B). Putting a finger fix the conductor in the artery and warn the formation of hematoma in the field of puncture.

A catheter with pointed and tightly fitted to the diameter of the conductor in the conductor is put on the outer end of the conductor, move it to the skin of the thigh and the conductor is introduced into the clearance of the arteries (Fig., D). The catheter, together with the protruding of it, the soft tip of the conductor is promoted under the control of the X-ray screen, depending on the objectives of the study (general or selective arteriography) in the left hearts, aorta, or one of its branches. Then an X-ray-repeat substance is introduced and a series of radiographs produce. If it is necessary to register pressure, taking p. Blood or the administration of medicinal substances, the conductor from the catheter is removed, and the latter is washed with isotonic P-r-sodium chloride. After the end of the study and extract the catheter to the place of puncture impose a gulling bandage.

Complications (hematoma and thrombosis in the field of puncture of the femoral artery, perforation of the arteries, aortic or heart walls) with technically correctly performed by S. m. It is rare.

Bibliography: Petrovsky B. V. and others. Abdominal aortography, Vestn. Hir., Vol. 89, No. 10, p. 3, 1962; S E 1 D I P-G EG S. I. Catheter Replacement of the Needle in Percutaneous ARTERIOGRAPHY, ACTA RADIOL. (Stockh.)., V. 39, p. 368, 1953.

Puncture of the femoral artery for hermerder

The puncture of the Seldgere is carried out in order to introduce into the aorta and its branches of the catheter, through which the contrasts of the vessels can be contrasting, probing the heart cavities. Internal diameter of 1.5 mm internal diameter of 1.5 mm is carried out immediately below the groove bunch for the projection of the femoral artery. Through the surveillance of the needle entered in the artery, the conductor is introduced first, then the needle is removed and instead of it on the conductor put on a plastic catheter with an outer diameter of 1.2-1.5 mm.

The catheter together with the conductor is promoted by the femoral artery, the iliac arteries in the aorta to the desired level. Then the conductor is removed, and the syringe with a contrasting substance is attached to the catheter.

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Puncture of the femoral artery for hermerder

Catheterization of the femoral artery according to the method of services

NB. If the patient immediately before the operation with artificial blood circulation is exposed to angiography through A. Femoralis, never delete the catheter (inverter) through which the procedure was carried out. Removing the catheter and imposing a compression bandage. You will subjected the patient at risk of developing unnoticed blood bleeding ("under sheets") against the background of total heparinization. Use this catheter to monitor pressure.

Angiography of the arterial system. Types of access to arteries.

Technique of translumal puncture of abdominal aorta.

The patient's position is lying on the stomach, the hands bent in the elbows and fell under the head. Landmarks for puncture serve the outer edge of the left M.EERECTOR Spinae and the lower edge of the XII edge, the intersection point of which is the place of the needle ins. After anesthestics of the skin 0.25-0.5%, the novocaine solution makes a small incision of the skin (2-3 mm) and the needle is guided forward, deep into the medial at an angle of 45 ° to the patient's body surface (approximate direction on the right shoulder). In the course of the needle, infiltration anesthesia is carried out with a solution of novocaine. Upon reaching the para -ortal fiber, the transfer fluctuations of the aorta wall are clearly felt, confirming the correctness of the puncture. In para -ortal fiber, a "pillow" is created from novocaine (40-50 ml), after which the aorta wall is pierced with a short sharp movement. Evidence that the needle is in the lumen of the aorta, is the appearance of a pulsating blood jet from the needle. The needle movement is constantly controlled by fluoroscopy. Through the surveillance of the needle in the aorta, the conductor and the needle is introduced. More often use the middle puncture of the aorta at the L2 level. With suspected occlusion or aneurysmatic expansion of the infrared aorta, the high puncture of the Supless Division of the Abdominal Aorta at the TH12-L1 level is shown. Translumal puncture technique for abdominal aorta angiography is almost always a forced measure, since the required volume and the rate of introducing a contrast agent on ordinary angiographic equipment (50-70 ml with a speed of 25-30 ml / s) can be administered only through rather large diameter catheters - 7-8 F (2.3-2.64 mm). Attempts to apply these catheters for transaxillious or cubital arterial access are accompanied by various complications. However, with the development of digital subtractive angiography, when it became possible to enhance the X-ray-repeat image of the vessels after administration of a relatively small amount of contrast agent, the catheters of small diameters 4-6 f or 1.32 became increasingly used. Such catheters allow you to safely and expediently carry out across the arteries of the upper extremities: cercel, shoulder, elbow, radiation.

Methods of puncture of the common femoral artery in the Seldgere.

The puncture of the femoral artery is performed by 1.5-2 cm below the tippact bundle, in the place of the most clear ripple. Having determined the pulsation of the common femoral artery, the local infiltration anesthesia is carried out with a novocaine solution of 0.25-0.5%, but so as not to lose the pulsation of the artery; Inhalation, infiltrate the skin and subcutaneous fiber on the right and to the left of the artery to the supervisor of the LONA bone. It is important to try to lift the artery from the bone bed on the bone, which facilitates the puncture, as it brings the wall of the artery to the skin surface. After completion of the anesthesia, they make a small impression of the skin (2-3 mm) to facilitate the needle. The needle is carried out at an angle of 45 °, fixing the artery by the middle and index fingers of the left hand (when puncture of the right femoral artery). When her end comes into contact with the front wall of the artery, you can feel the pulse shocks. The puncture of the artery should be carried out by a sharp short movement of the needle, trying to punish only the front wall. Then the blood stream comes immediately through the needle clearance. If this does not happen, the needle is slowly tightened back until the blood jet appears or before the release of the needle from the puncture channel. Then you should repeat the attempt to puncture. The arterily is pierced with a thin needle with an outer diameter of 1 - 1.2 mm without a central mandreten with a slamming both in the antegrade and in the retrograde direction, depending on the purpose of the study. When a jet of blood appears, the needle tip the patient to the hip and the conductor is introduced through the channel in the clearance of the arteries. The position of the latter is controlled by fluoroscopy. Then the conductor is fixed in the artery, and the needle is removed. According to the conductor in the clearance of the arteries, a catheter or an introducer is installed with long interventions with the change of catheters. In cases where femoral arteries cannot be punctured, for example, after shunt operations or occlusive diseases, when the lumen of the femur, the arteries of the pelvis or the distal Aorthi Division, alternative access should be applied.

Such access may be axillary or shoulder artery, transciliation puncture of abdominal aorta.

Contralateral female access.

Most endovascular interventions on iliac arteries can be performed with the help of the ipsilateral femoral artery. However, some damage, including stenosis of the distal part of the outer iliac artery, are not available from the ipsilateral common femoral artery. In these cases, the method of contralateral access is preferred; In addition, it allows interference with the multi-level stenosis of the femoral and illegal and femoral zone. To pass through bifurcation, the aorta usually use Cobra, Hook, Sheperd-Hook catheters. Contracting access to stenting and endoprosthetics of the artery can be difficult when using balloon-expanded stents relative to the rigid design. In these cases, a long interodouser should be applied on the Amplatz Syper Stiff rigid conductor and others. Contractor access technique has some advantages compared to antitegudic access when interventions in the femoral-poned zone. The first - retrograde conducting a catheter allows you to interfere with the proximal portion of the femoral artery, which would be unavailable at the antegradine puncture. The second aspect is an attachment of the artery for the exercise of hemostasis and the imposition of a gone aseptic dressing after the intervention occurs on the opposite side of the operation, which ultimately reduces the frequency of early postoperative complications. Antitegrad female access. The technique of anteadic access is used by many authors. This type of intervention provides more direct access to many damages in the middle and distal part of the femoral-populated artery segment. The closest approach to stenosis and occlusion in the ancient arteries provides more accurate instruments management. However, in addition to potential advantages, anthrame equipment has disadvantages. To accurately enter the surface femoral artery, a higher puncture of the common femoral artery is necessary. The artery puncture above the groove bundle can lead to a formidable complication - retroperitoneal hematoma. Tries such as the introduction of a contrast preparation through a puncture needle help identify the anatomy of the bifurcation of the common femoral artery. To better display it uses a slanting projection to open the bifurcation angle.

Approximately 20-30% of the standard cases of the technique of antegrade and contralateral access to the femoral artery is not able to ensure the delivery of tools to the occlusive sections of the surface femoral arteries. In these cases, the technique of popling access is shown, which is used only in patients with passable distal segments of the surface femoral artery and proximal segments of the popliteal artery. A safe puncture of the patellied artery can be carried out only by more subtle instruments with a diameter of not more than 4-6 F. When using such tools such as borants, dilatation cylinders with stents, it is permissible to use intro-seater 8-9 f, as the diameter of the artery in this place is 6 mm . The technique of puncture of the popliteal artery is similar to the technique of the points described above. The poplled artery along with the nerve and Vienna passes from above along the diagonal of the poned triangle. The surface arrangement of the artery in this place allows its retrograde puncture, which is performed precisely over the joint. In this case, the patient lies on the stomach or on the side. Manipulations are performed under local anesthesia.

Access through the shoulder artery.

Shoulder access is an alternative technique for conducting instruments in the aorta and its branches, often used for diagnostic procedures if it is impossible to carry out a femoral artery puncture or aortic transluper puncture. In addition, this access may be an alternative approach to endovascular interventions on renal arteries. It is preferable to use the left shoulder artery. This is dictated by the fact that the catheterization of the right-handed artery significantly increases the risk of cerebral vessels when carrying out tools through the aortic arc. The puncture of the shoulder artery must be performed in its distal part above the cubital fossa. In this place, the artery lies the most superficially, hemostasis can be facilitated by pressed the artery to the shoulder bone.

Radial access through radiation artery is accompanied by a trauma of a smaller than the femoral artery, a vessel, which allows you to do without an indispensable long hemostasis, resting period and beddown after endovascular intervention. Indications for radial access: good ray artery pulsation with adequate collateral blood circulation from the elbow artery through the palm arterial arc.

To do this, use "Allen-test", which must be carried out by all patients - candidates for radial access.

The survey is carried out as follows:

Attach radiation and elbow artery;

6-7 flexing-extensible movements of the fingers;

With the disintegrated fingers, the simultaneous compression of the elbow and radial arteries continue. The skin of the hand is palenet;

Remove the lunch of the elbow artery;

Continuing the pressing of the radial artery, control the color of the brush skin. Within 10 with skin color, the brush should return to normal, which indicates sufficient development of collaterals. In this case, the "allen-test" is considered positive, radial access is admissible. If the skin color of the brush remained pale, "Allen-test" is considered negative and radial access to unacceptable.

Contraindications for this access - the absence of a pulse of the radial artery, negative "allendest", the presence of arteriovenous shunt for hemodialysis, very small radiation artery, the presence of pathology in. Proximal arteries need tools with dimensions more than 7 F.

Technique of radial arterial access. Before performing the puncture, the direction of the radial artery is determined. The artery puncture is carried out by 3-4 cm for a proximal cylinding radiation bone process. Before the bunch, local anesthesia is performed by a novocaine solution or lidocaine through a needle carried out parallel to the skin, so as to eliminate the puncture of the artery. The suction of the skin must also be carried out with great care to avoid artery injury. The puncture is produced by an open needle at an angle of 30-60 ° to the skin in the direction of the artery.

Technique direct catheterization of carotid arteries. The puncture of the overall carotid artery is used for selective studies of the carotid arteries and the arteries of the brain. The benchmarks are M.Sternocleidomastoideus, the top edge of the thyroid cartilage, the pulsation of the total carotid artery. The top edge of the thyroid cartilage indicates the location of the bifurcation of the common carotid artery. After anesthesia, they make a puncture of the skin with the tip of the scalpel, M.Sternocleidomastoideus pushes the dust and needle forward towards the ripples of the total carotid artery. It is very important that the pulse shocks feel not on the side of the tip of the needle, but immediately in front of it, which indicates the orientation of the needle to the center of the artery. This avoids the tangent wounds of the artery and treatment of the hematoma. The artery is punctured by a short dosage movement. When a jet of blood appears through the magnitude of the needle, the explorer and the needle is introduced into the artery. According to the conductor in the clearance of the arteries, a catheter is installed, the type of which depends on the purpose of the study.

Open access. Large diameter tools due to the danger of damage to the artery do not apply, open access to vessels carry out arteriotomy. Toolkit, dose and speed of insertion of a contrast agent. For thoracic and abdominal aortography, catheters are needed caliber 7-8 F length 100-10 cm, which ensure the rate of administration of a contrast preparation to 30 ml / s; And for peripheral and selective angiography - catheters 4-6 F length 60-110 cm. Typically, catheters with the configuration "Pig Tail" are used for injection of a contrast agent - "piglery tail" and brooded side holes. The contrast agent is usually administered by an automatic injector. For selective angiography, the catheters of other configurations are used, each of which provides selective catheterization of the mouth of a single artery or group of the branches of the aorta - coronary, brachiocephalic, viscerals, etc. At the same time, to obtain angiograms, it is often quite enough to use the contrast agent manually. Currently, non-ionic water-soluble contrast agents containing from 300 to 400 mg of iodine in 1 ml ("Ultravist-370", "Omnipak 300-350", "Visipak320", Ksenietix-350, etc.) are used for angiography. In rare cases, a previously used water-soluble ion contrast 60-76% urographic drug, which, due to pronounced pain, nephro and neurotoxic effects, should be limited to the diagnosis of distal lesions of the arterial bed or used under intubation anesthesia intubation anesthesia. The rate of administration of a contrast agent should make measurement with the technique of shooting and at the rate of blood flow. For injection into the chest aorta, the speed of 25 to 30 ml / s is adequate; For abdominal aorta - from 18 to 25 ml / s; For peripheral arteries (pelvic, femoral) - speed from 8 to 12 ml / s using from 80 to 100 ml of a contrast agent. This ensures the visualization of the arteries of the lower extremities up to the stop. The shooting speed for thoracic aortography is usually from 2 to 4 frames / s; For abdominal aortography - 2 frames / s; for limbs in accordance with the speed of blood flow - 1-2 frames / s; For pelvis - 2-3 frames / s and for vessels of the heads - from 1 to 1 frame / 3 s. Digital subtractive angiography requires smaller volume and lower rate of administration of a contrast agent. So, for abdominal aortography, it is sufficient to introduce 20-25 ml of X-ray189 contrast agent at a rate of 12-15 ml / s. And in some cases, it is possible to obtain aortiodograms with the introduction of an x-ray-contrast to the venous direction. It should be noted that it takes a sufficiently large volume of the contrast agent - up to 50-70 ml, and the resulting angiograms will correspond to the quality of survey - common angiograms. The greatest permission of DSA is achieved with a direct selective introduction of a contrast agent in the test vessel with the so-called postprocessional computer processing - subtraction of a mask (skeleton and soft tissue), the summation of the image, amplification and underline the vascular pattern of angiograms, longitudinal or volumetric reconstruction of images of several anatomical regions in one whole.

An important advantage of modern angiographic devices are the possibilities of direct intraoperative measurement of the diameter of the vessels, the parameters of the stenosis or the anneurysm of the artery. This allows you to quickly determine the tactics of x-ray-thrust intervention, to accurately choose the necessary tools and implantable devices. Complications. Any radiocontrase studies are not absolutely safe and associated with a certain risk. Possible complications include external and internal bleeding, thrombosis, arteries embolism, perforation of a non-paved vessel wall by conductor or catheter, extravasive or intramural administration of a contrast agent, an explosion of conductor or catheter, reactions associated with the toxic effect of contrast agents. The frequency and type of complications occurring during the puncture of the arteries are different depending on the place of catheterization. The frequency of complication is different: for example, with femoral access - 1.7%; with translumal - 2.9%; With shoulder access - 3.3%. Basic complications: Bleeding can be external and internal (hidden) with the formation of pulsating hematoma and further pseudo-oscillage; Thrombosis occurs with long vessel occlusion or its dissection; However, the frequency of it has significantly decreased using catheters and conductors of a smaller diameter, a decrease in the operation time and the improvement of anticoagulant drugs; Embolism develops in the destruction of atherosclerotic plaques or tombing of blood clots from the arterial wall. The nature of complications depends on the size of the embol and a specific vessel, blood supply to this arterial pool; Arteriovenous fistulas can be formed as a result of simultaneous puncturing of the artery and veins, most often in feast. The conditions for the safety of the aortoarteriography are strictly compliance with the testimony, contraindications and a rational choice of research methods, conducting a number of preventive measures aimed at combating potential complications (washing the needles, catheters and connective tubes isotonic sodium chloride solution with heparin, careful testing of the toolkit). Manipulations with the conductor and catheter should be short and small-tummed. During the entire diagnostic study or therapeutic x-ray mercycic intervention, ECG control, blood pressure, blood coagulation time is necessary. Anticoagulants, antispasmodics, desensitizing propair190 Fig. 2.33. Puncture of the inner jugular vein, and is the first method; B - the second way. Rati also contribute to the prevention of complications and are the key to reducing the risk of angiography. With proper puncture and technique of handling the catheter, as well as the use of non-ionic or low-grained contrast agents, the frequency of complications with angiography is less than 1.8%.