血液凈化原理,模式及治療的選擇

TipsforimprovingfilterlifeAquariusSystemCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.PM-0063-11/2015-1

目前一頁\總數六十六頁\編于點腎臟替代治療“的內容腎臟替代治療的基本內容濾器的選擇抗凝劑的應用目前二頁\總數六十六頁\編于點

3CRRT命名的發展CRRT：Continuousrenalreplacementtherapy（連續腎臟替代治療）ICBP:Intensivecarebloodpurification（重癥血液凈化）CBP：ContinuousBloodpurification（連續血液凈化）MOST：MultiOrganSupportTherapy（多臟器支持療法）目前三頁\總數六十六頁\編于點

4CRRT的特點和優越性

CRRT是緩慢、連續排除水分，模擬尿的排泄方式。更符合生理狀態，能較好地維護血流動力學穩定；容量波動小；溶質清除率高；有利于營養改善及能清除細胞因子，從而改善危重ARF患者的預后，更好的血液動力學穩定性更好的溶液控制能力和清除多余水分累積的更好溶質清除性維持尿排泄并保存殘余腎功能清除炎癥介質改善營養支持目前四頁\總數六十六頁\編于點

5

CRRT的分類SCUF-緩慢連續超濾CAVH-連續動靜脈血液濾過CVVH-連續靜靜脈血液濾過HVHF－高容量血液濾過CAVHD-連續動靜脈血液透析CVVHD-連續靜靜脈血液透析CVVHFD－連續靜靜脈高通量透析CAVHDF-連續動靜靜脈血液透析濾過CVVHDF-連續靜靜脈血液透析濾過MPS-血漿置換HP-血液灌流和免疫吸附CRRT以一種更符合機體生理特性的方式，連續地清除機體多余的水分和毒素，調節酸堿和電解質的平衡，來有效地維持機體內環境的穩定。不單用于急性腎衰，還是救治許多危重病癥的有力輔助手段。目前五頁\總數六十六頁\編于點

6原理與機制彌散對流吸附500500050000目前六頁\總數六十六頁\編于點SoluteClassesbyMolecularWeightDaltons?

InflammatoryMediators(1,200-50,000)“small”“middle”“large”目前七頁\總數六十六頁\編于點Jean-MichelLannoyNikkisoABPDirector8炎癥介質的特征介質分子量C3a2500C5a2800TNF-a17500x3C5a2800IL-62125000IL-1Ra14000IL-89000LPS100000FactorD2300023000目前八頁\總數六十六頁\編于點Jean-MichelLannoyNikkisoABPDirector9炎癥介質的特征介質蛋白結合分子量C3ano2500C5ano2800TNF-a部分17500x3STNRFIyes55000STNRFIIyes75000IL-621yes25000IL-1Rano14000IL-lano89000PAF部分450FactorDyes23000目前九頁\總數六十六頁\編于點5/8/202310PSHF系列濾器篩選系數/高截留分子量目前十頁\總數六十六頁\編于點如何選擇血濾器？Jean-MichelLannoyNikkisoABPDirector11目前十一頁\總數六十六頁\編于點MolecularWeights（分子的重量或分子量的大小）12Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730目前十二頁\總數六十六頁\編于點NewfunctionalmembranewithdefinedlargerporesizeHCOmembrane目前十三頁\總數六十六頁\編于點<0,01μm<0,02μm~0,09μm~0,30μm:porediameterhighfluxhighcut-off*proteinseparationmembraneplasmaseparationmembraneVariationofmembraneporesizeElectronmicrographsofinnermembranesurface目前十四頁\總數六十六頁\編于點sievingcoefficient100100010000100000100000000.20.40.60.81Molecularweight[D]ClassicalFilter30kDhumankidneyhighcut-offHighCut-OffHemofilter目前十五頁\總數六十六頁\編于點SievingCoefficientAsievingcoefficientisthemeasureofhoweasilyasubstancepassesfromthebloodcompartmenttothedialysatecompartmentinahaemofilter.Thus,asievingcoefficientof1.0meansthesoluteis100%filterable;i.e.inahaemofilter,thesolutewillequilibrateonbothsidesofthemembrane.So…thereturningbloodandtheeffluentbothhavethesameconcentration(50:50).Anexampleispotassium(sievingcoefficientis1.0)Asievingcoefficientof0meansthesolutedoesnotcrossthemembrane,eg.albumin.Ofcourse,thisalldependsonthemembrane,andsievingcoefficientswillvarydependingontheporesize.DEFINITION:Thecut-offpointofasoluteforanymembraneisasievingcoefficientof0.1.Thismeansthat10%ofthemoleculeswillpassand90%willnotpass.16Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前十六頁\總數六十六頁\編于點MolecularWeight[Da]StandardHighFluxHighCut-OffHF,UF=1L/h,t=2hMedian,25th-75thpercentiles)ICM(2002)28:651-655HCOMembranewithincreasedpermeabilityforinflammatorymediatorsmembranecharacteristics

目前十七頁\總數六十六頁\編于點Molecularweight18Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.HF1200HaemofilterCut-Off55000daltons目前十八頁\總數六十六頁\編于點ComparisonofInterleukin-6RemovalPropertiesamongHemofiltersConsistingofVaryingMembraneMaterialsandSurfaceAreas5/8/202319RecentStudiesinMembrane目前十九頁\總數六十六頁\編于點20全身抗凝

局部抗凝

無肝素抗凝肝素低分子肝素鈣魚精蛋白枸櫞酸抗凝的選擇Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十頁\總數六十六頁\編于點積極主動預防管路的凝血

利用重新預沖和循環模式清除管路及濾器中的氣泡

仔細觀察預沖后管路的通暢.保持靜脈壺的血液水平在二分之一以上，

減少氣血接觸防止靜脈小壺的凝血，靜脈

小壺的凝血影響了血液的流速壓力降21Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十一頁\總數六十六頁\編于點預防濾器內的凝血(FiltrationRatio%)保持超濾比率在25%一下.超濾比率是衡量濾器中

血液濃度(血流速率與濾出是百分比）.是多少血夜

進入濾器和多少液體排除的比較。

目標血流速度的目的制定達到低的超濾比率，

從而達到更長的濾器使用壽命.高的血流速度可以達到低的超濾比率

如果臨床需求允許可以提高血流速10—15%當連接病人時，可以延長治療直到血流速度達到要求盡可能的在病人開始治療時防止血液的濃縮22Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十二頁\總數六十六頁\編于點預防濾器內的凝血(Recirculation)

重復循環模式：連接病人之前重復循環20-40/min，

重復循環可以侵泡濾器的纖維，同時排空纖維中的

空氣.濾器的纖維經過侵泡更加的飽滿，改善血流通過

纖維的流量，排除極小的氣泡防止早期的凝血.

一個循環時間在20–20/minutes.濾器和管路基本可以

72小時使用,

但這包括重復使用的時間.23Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十三頁\總數六十六頁\編于點FiltrationFraction（濾過分數）FiltrationFraction濾過分數是

總液體通過

濾器的量與超濾量的相比

濾過分數通常是盡可能的低，理想是25%

FiltrationFraction濾過分數是

不會受到前

稀釋泵的影響FiltrationFraction濾過分數是會受到血流速

的影響.

24Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十四頁\總數六十六頁\編于點超濾比率FiltrationRatio25Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.FiltrationRatio是表示濾器中血液濃度增加.理想的超濾比率在低于

25%.FiltrationRatio是受到前稀釋泵的影響.FiltrationRatio是受到血流速的影響.目前二十五頁\總數六十六頁\編于點FiltrationRatioandbloodpumpspeed

Postdilution(l/h)BloodPumpSpeed(mls/min)60(mins)=FiltrationRatio /1000

3l/hExchange

3

1

100mls/minx60mins=6=2=50%FiltrationRatio/1000

3l/hExchange

3

1

200mls/minx60mins=12=4=25%FiltrationRatio

3l/hrExchange

3

1

300mls/minx60mins=18=6=17%FiltrationRatio

26Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十六頁\總數六十六頁\編于點肝素是如何工作的?Heparin肝素抑制導致血液凝固和纖維蛋白凝塊形成的反應.肝素在抗凝系統中是多部位的作用.小劑量的肝素，與抗凝血酶III結合，

可以抑制凝血酶塊的形成通過消除

FactorX因子.減少了凝血素轉化成凝血酶治療劑量的肝素有利于血濾器的壽命.5Roncoetal.Effectsofdifferentdosesincontinuousveno-venoushaemofiltrationonoutcomesofacuterenalfailure:aprospectiverandomisedtrial.Lancet.2000Jul1;356(9223):26-30Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十七頁\總數六十六頁\編于點肝素;優勢和劣勢優勢:

容易管理和監控

ICU非常熟悉肝素抗凝.

便宜.

短的半衰期.

肝素可以中和.缺點:

增加出血的風險.

血小板減少.

增加肝素的劑量.

抗凝血酶元水平下降會影響肝素的作用.

Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十八頁\總數六十六頁\編于點枸櫞酸是如何工作的?枸櫞酸螯合了血循中的鈣.抑制了凝血ACD-A(CitrateSolution)WhatcitratebindstocalciumwhichinhibitscoagulationCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前二十九頁\總數六十六頁\編于點合適的枸櫞酸劑量30離子

Calcium50%1.1–1.3

mmol/l蛋白

Calcium40%0.95–1.2

mmol/l復合

Calcium10%0.1mmol/l圖表顯示鈣在血漿中的分布情況.枸櫞酸劑量考慮是

TotalCalcium(typically2.2-2.6mmol/l)andTotalMagnesium(typically1.1–1.4mmol/l).影響到選擇枸櫞酸的量

Citratedosingbetween3.3–4.0mmol/l.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前三十頁\總數六十六頁\編于點WhatdoesthebodydowithCitrate?Citrateisconvertedintocitricacid.轉化成枸櫞酸Yielding/resultinginthereleaseofbicarbonate.釋放碳酸鹽AlsometabolisedintheKrebscycleintheliver,skeletalmuscleandrenalcortex.（肝臟，肌肉，腎皮質）Ormetabolisedintoglucose代謝到糖.Excreted分泌，排泄.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前三十一頁\總數六十六頁\編于點Therapymonitoring32Theselectionandadjustmentoftherapyparameters,replacementfluidsandanticoagulantfluidsremainsaprescriptionatthephysician'sdiscretion.Achangeinanindividualprescriptionwillrequirephysicianrevieworbeclearlydefinedinalocallyapproveddocument.Tomonitorandadjustthetherapy,thefollowingtypicalparametersmaybeconsideredintheindividualizedprescriber’slocalprotocol:IonisedCalcium(afterhemofilter)typically0.25-0.35mmol/lIonisedCalcium(frompatient)typically1.05-1.3mmol/lTotalCitrate(frompatient)typicallylessthan2.5mmol/lCalciumRatio(acomparisonofCalciumdistribution)typicallylessthan2.3Acid/basemonitoringElectrolytesmonitoringFluidbalancemonitoringCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前三十二頁\總數六十六頁\編于點AquariusRegionalCitrateAnticoagulationProtocolJohnRProwleMDFRCPFFICMAdultCriticalCareUnitRoyalLondonHospital目前三十三頁\總數六十六頁\編于點EligibilityforRCARequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationorunabletoachieveadequatefilterlifespan(>12h)usingheparinAppropriatelytrainednursingstaffavailable目前三十四頁\總數六十六頁\編于點Contra-indicationstoRCAinpilotRequirementforsystemicanticoagulant(otherthanprophylaxis)ChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR>2orLactate>4μmol/LPost-hepaticresectionSevereshock:Noradrenaline>0.5mcg/kg/minand/orLactate>4μmol/LArterialBloodIonizedCalcium<0.8μmol/LatcommencementofRCAArterialBloodpH>7.5orHCO3-

>40mmol/LatcommencementofRCASerumSodium<120or>160atcommencementofRCAUncontrolledhyperglycaemia>6U/hInsulinIBW>90kg目前三十五頁\總數六十六頁\編于點35ml/kg/hCVVHRCAProtocolAllpatientswillstartat35ml/kg/hunlessdirectedbyphysicianDoseincludescitratevolumepre-filterFiltrationRatiois20%Pre-filtercitrateconcentrationwillbe~2.8mmol/LIBWkgPost

–dilutionmL/hBloodPumpmL/minACD-A

(Citrate)mL/h<50140012018050-59180015023060-69210018027070-792400200300>802700230350Protocol1目前三十六頁\總數六十六頁\編于點CalciumReplacementAccusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10mlampuleofCalciumChloride(10mmol)in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius-CitratedeviceonlyInfusionrate0-175ml/h目前三十七頁\總數六十六頁\編于點InitialCalciumRateThencheckarterialCaiin1hSystemiciCaInitialrateofCaClsolution<0.8DoNOTcommenceRCAMedicalteamtoreview&correctCalcium0.8-0.975mL/h(0.75mmol/h)0.9-1.050mL/h(0.5mmol/h)>1.00mL/h(0mmol/h)Usethistable

onlywhenfirststartingRCA目前三十八頁\總數六十六頁\編于點AdjustingCalciumInfusion[iCa]CaClinfusionadjustment(MAXIMUMRATE=175mL/hr):Recheck<0.8Doctortogive5ml,10%CaCl(3.4mmol)‘minijet’byslowIVbolusviaacentrallineimmediatelyIfCaClalreadyrunningthenincreaseinfusionby50ml/hIfstartingCaClthenstartat100ml/hIfCaClinfusionalreadyat175ml/hceaseRCA

&informICUConsultant1h0.8-0.89IfCaClalreadyrunningthenincreaseinfusionby25ml/hIfstartingCaClthenstartat75ml/hIfCaClinfusionalreadyat175ml/hceaseRCA&informICUConsultant3h0.9-1.3Nochange3h*>1.3DecreaseCaClinfusionby25ml/hIfCaClinfusionoffthenchecksystemic[iCa]in3hoursInformDoctorif[iCa]risesto>1.53h*Likelytochangetocheckin6hinfinalprotocol目前三十九頁\總數六十六頁\編于點MonitoringBaselineABGfor

iCa2+&HCO3-LabBloodswithin12hforU&EMg2+TotalCa2+Aftertheonehour:

ABGforiCa2+&HCO3-Thereafterevery3h*:ABGforiCa2+&HCO3-monitoring(unlessearliercheckrequiredafteradjustmentofCalciuminfusion)Aroundevery12hours:LabBloods:U&E;TotalCa2+;Mg2+

(AimMg>1mmol/L)PostFilteriCa2+(Takefromreturn-linesampleport)RecordallResultsonRCAPro-forma*Likelytochangetocheckin6hinfinalprotocol目前四十頁\總數六十六頁\編于點Start35ml/kg/hCVVHIfpH>7.5orHCO3->40Reduceto25ml/kg/hIfpH>7.5orHCO3->40Use25ml/kg/hwith25%FRIfpH>7.5orHCO3->40StopRCAMetabolicAlkalosisMonitorpHandBicarbonate3hly**Likelytochangetocheckin6hinfinalprotocol目前四十一頁\總數六十六頁\編于點IBWkgPost

–dilutionmL/hBloodPumpmL/minACD-A

(Citrate)mL/h<50110010015050-59130011017060-69150013020070-791700140210>801900160240IBWkgPost

–dilutionmL/hBloodPumpmL/minACD-A

(Citrate)mL/h<50Reachedminimumbloodflowrate–DISCONTINUERCA50-59Reachedminimumbloodflowrate–DISCONTINUERCA60-69150010015070-791700120180>801900130200Step2:ifpH>7.5orHCO3->40mmol/LonProtocol2changesettingstoProtocol3(25ml/kg/hwithincreasedfiltrationratio)belowandmonitorevery3h*Step3:ifstillpH<7.5orHCO3->40mmol/LDISCONTINUERCAStep1:

ifpH>7.5orHCO3->40mmol/LonProtocol1

ChangethesettingstoProtocol2(25ml/kg/h)belowandcontinuetomonitorevery3h*.(Protocol2mayalsobeselectedfordosereduction)Protocol2Protocol3*Likelytochangetocheckin6hinfinalprotocol目前四十二頁\總數六十六頁\編于點Howitworks…目前四十三頁\總數六十六頁\編于點Jean-MichelLannoyNikkisoABPDirector44目前四十四頁\總數六十六頁\編于點THANKS!5/8/202345目前四十五頁\總數六十六頁\編于點IndicationsforCitrateAnticoagulationRequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前四十六頁\總數六十六頁\編于點ContraindicationsChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR>2orLactate>4μmol/LPost-hepaticresectionSevereshock:Noradrenaline>0.5mcg/kg/minand/orLactate>4μmol/LArterialBloodIonizedCalcium<0.8μmol/LatcommencementofRCAArterialBloodpH>7.5orHCO3-

>40mmol/LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant(otherthanprophylaxis)SerumSodium<120or>160atcommencementofRCAUncontrolledhyperglycaemia>6U/hInsulinIBW>90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.10Prowleetal.ServiceDevelopmentPlanandProtocolforRegionalCitrateAnticoagulation,TheRoyalLondonHospital目前四十七頁\總數六十六頁\編于點TherapymonitoringIonisedCalcium:

Ionizedcalciumisameasureoffreecalcium.

Afterhemofiltertypically0.25-0.35mmol/l

Frompatienttypically1.05-1.3mmol/lTotalCalcium:

Totalcalciumincludesbothprotein-boundandfreecalcium.

TotalCalcium(frompatient)typicallylessthan2.5mmol/lAcid/basemonitoring:SystemicpHwillbemonitored3-6hrly.Glucosemonitoring:Bloodglucosemonitoredforhyperglycaemia3-6hrlyElectrolytemonitoring:Levelstobemonitored3-6hrly.Fluidbalancemonitoring.Anyotherclinicalsigns?Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前四十八頁\總數六十六頁\編于點OptimizeVascularAccessConsiderusingahighflowsiliconevascularaccesscatheterthatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.AvoidattachingtheAquariustoacatheterwithpoorflow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Considerrotatingthehubofthecatheter90°sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Considerthepatientsintravascularvolume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.49Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前四十九頁\總數六十六頁\編于點OptimizeAnticoagulationHighreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulation

adjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.50Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前五十頁\總數六十六頁\編于點Theeffectofbloodpumpspeed51Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.目前五十一頁\總數六十六頁\編于點TheeffectofPre-dilution52Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.目前五十二頁\總數六十六頁\編于點Considerations53Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicity

andbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnection目前五十三頁\總數六十六頁\編于點PatientPreparation54Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstances目前五十四頁\總數六十六頁\編于點CatheterCharacteristics

55Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.

Easeofinsertion:toavoidvesseltraumaGoodflowcharacteristics:tooptimisebloodflowKinkresistant:toavoidaccesspressureproblemsBiocompatible:toreducecomplicationrisksAmenabilitytoguidewirechange:tooptimisetherapy目前五十五頁\總數六十六頁\編于點Side-by-SidePolyurethaneCatheters56Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.目前五十六頁\總數六十六頁\編于點CoaxialPolyurethaneCatheters57Copyright?20