Читать книгу Interventional Cardiology - Группа авторов - Страница 53

Multiple micropuncture kits are being increasingly available for commercial use and the micropuncture technique proved to reduce vascular complications in an exploratory yet prematurely terminated randomized trial [16]. The ideal puncture location is identified by fluoroscopy or ultrasound as described earlier. A 21 Gauge needle (as compared to the standard 18 Gauge needle) is inserted in the artery using the standard Seldinger technique. When blood backflow is observed (take care to be less brisk than with the larger conventional needles), the 0.018 in guidewire is inserted. We suggest that the straight wire on fluoroscopy be followed, as it may engage small arterial branches. A 4 Fr introducer sheath is inserted over the wire and an angiogram performed to assess the puncture location. If the puncture site is correct the procedure follows in the usual manner with sheath upsizing as needed over an 0.035 in normal or stiff guide wire. Otherwise, the 4 Fr sheath is removed and manual compression for 5 minutes is applied before further attempts are made. The main advantage of this approach is that bleeding through these small punctures tends to stop quickly and normally does not recur even under full anticoagulation. Some needles are also longer and more echoreflective than normal Seldinger needles, facilitating US guided punctures.