シャドーイング練習: Femoral access: step-by-step and troubleshooting - Mazen Abu-Fadel, MD - YouTubeで英語スピーキングを学ぶ
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Welcome to Cardiovascular Innovations 2020.
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Welcome to Cardiovascular Innovations 2020.
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My name is Mazan Abu-Fadal
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and I'm an interventional cardiologist at the Oklahoma Heart Hospital North Campus
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and a clinical professor of medicine at the University of Oklahoma.
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Today we're going to be discussing femoral access,
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step by step, and troubleshooting.
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I have no disclosures related to this talk.
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Of course, whenever possible, radial first is a good idea.
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However, femoral access is still needed for a variety of procedures,
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and knowing how to do good femoral access can save the patient a lot of complications.
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The ideal puncture site is what we're going to start with.
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If we can puncture the femoral artery right in the middle of the head of the femur with one anterior stick,
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the risk of complications is going to be much less than
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if we puncture the femoral artery above the most inferior border of the inferior epigastric artery,
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or if we puncture the femoral artery below the most inferior border of the head of the femur.
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Even though we may still be in the common femoral artery,
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this can still cause complications because manual pressure is not going to give us good.
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This is because this area of the common femoral artery above the femoral head
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is the closest to this bony landmark where compression can cause hemostasis.
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Access above or below the femoral head is going to increase complication rates.
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And another important thing we can see from this picture is how the femoral artery,
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when it transitions to the iliac artery,
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starts diving down into the pelvis.
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This is important when we're talking about ultrasound.
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Now, first, we started using fluoroscopic markers to try and tell us where the femoral head is,
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where the inferior border is,
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and to try and start our axis at that point so we don't have low axis and hopefully not high axis.
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The problem with this approach is even
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when we put the landmark at the inferior border of the head of the femur
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and we start our axis at 45 degrees with the needle there,
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if the patient is very thin and there's not a lot of subcutaneous tissue,
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we're going to access that artery.
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On the other hand, if the patient actually has a lot of subcutaneous tissue and is obese,
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which is most of the patients we see these days,
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even when we start from the inferior border of the head of the femur,
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by the time the needle gets into the artery, it's already too high.
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Ultrasound guided access can help with that quite a bit.
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Ultrasound guided access can help with the artery and the bifurcation
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and can also help us detect the needle insertion in the anterior wall of the artery.
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Doing ultrasound requires some good technique and there's a learning curve.
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However, after around 15 procedures,
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you can be good at it.
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Usually we like to start looking with the ultrasound either at the inferior border
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or in the middle of the head of the femur
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and then scan up and down until we see the bifurcation
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and go above the bifurcation where the common femoral artery is located.
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The nice thing about the ultrasound is we can also do longitudinal views to see the wire,
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make sure it's not going sub-intimal
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or make sure there's not a lot of calcifications or disease in the artery before we even get access.
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Ideally, we want to get the access above the bifurcation of the femoral artery.
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So here, even though the sheath is perfect in the middle of the head of the femur,
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you can see it did go in the bifurcation.
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The goal is to have an access which is above the bifurcation in the common femoral artery
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and still below the most inferior border of the head of the,
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oh, sorry, of the inferior epigastric artery.
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This can be achieved with ultrasound guidance much better than with a fluoroscopic guidance.
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In addition, ultrasound guidance will help us decrease the number of attempts.
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First pass success rate is actually higher,
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time to sheet insertion is lower,
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and risk of venipuncture is lower.
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The use of micropuncture is also very important if used properly.
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When we get access with micropuncture,
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we are using it with ultrasound guidance,
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and we use the micropuncture that had the braided tip so
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that we can reflect the sound wave and see them on the ultrasound.
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After access obtained and the wire is advanced and before removing the needle,
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a quick fluoroscopy at the site of insertion will show you the transition between the needle head and the wire.
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If this transition is at the level of the middle of the head of the femur,
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then that's perfect.
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If it's too high or too low,
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then you want to repeat the access after you remove the wire and the needle and hold.
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There's been claims that micropuncture can increase vascular complications and specifically it can increase retroperitoneal bleeding.
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The micropuncture wire goes into one of the smaller pelvic wires like you see in panel A.
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This is why it's very important when you get access to look at the needle wire interface,
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and if it's too high like you see in the first panel,
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remove, hold pressure, then access again like you see in the middle panel.
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However, in the middle panel,
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after we got access and we advanced the wire a little bit,
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we took a fluoro and it was going in one of the pelvic arteries,
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which, especially if the wire is hydrophilic,
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can perforate that pelvic artery and cause bleeding and with anticoagulation retroperitoneal hematoma.
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This is why looking at the insertion site as well as the direction of the wire,
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make sure it's going in the iliac arteries up to the aorta.
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It's going to be very important before we exchange to the micropuncture dilator and wires.
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After coronary, sorry, after sheet insertion,
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you want to do femoral ingiography.
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Femoral ingiography is very important and in my opinion,
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should be done before the procedure is started and before any anticoagulation is given.
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You can see from this picture how the sheet is actually touching the wall of the artery,
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and if injection is being done,
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this can dissect the artery.
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This can be prevented from getting a wire through the sheath when taking ephemeral angiogram,
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which is standard we use all the time now.
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And this will deflect the tip of the sheath away from any tortuosity in the artery
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and allow you to inject even using an injector or a syringe without worrying about dissection.
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So what is the ideal technique for femoral access?
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Locate the femoral head.
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Make sure where the lowest point is and where the middle of the head of the femur is.
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Use ultrasound guidance to use a micropuncture with it and try to access the femoral artery at the correct level.
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Make sure you scan up and down to see the bifurcation.
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And when you're scanning up,
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if you see the femoral artery start to dive down into the tissue further away from the ultrasound,
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this means you're too high.
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You're most likely in the iliac arteries.
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After you put the, after you access with the needle and you advance the wire,
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take a quick flora, make sure the transition of the tip of the needle
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and the wire is in the middle of the head of the femur
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and make sure that the wire is going towards the aorta and not the pelvic arteries.
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After all that is done,
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put a wire through the sheath,
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take a femoral angiogram, and then if needed,
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you can upsize the sheath for structural interventions or hemodynamic support,
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or just give anticoagulation for your intervention.
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The femoral angiogram also helps you make sure the size of the artery is good
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and there's no disease or complications there that prevent you from using vascular closure devices if
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Thank you very much for your attention.
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For any questions or comments,
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please feel free to email me at this email.
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I hope you enjoyed this meeting.
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文脈と背景
この動画では、オクラホマハート病院の介入心臓専門医であるマゼン・アブ・ファデル医師が、フェモラルアクセスとそのトラブルシューティングについて詳細に説明しています。彼は、心血管分野での専門知識を活かし、フェモラル動脈へのアクセス方法やその際の注意事項を明確に解説しています。この情報は、心臓の手術や手技を行う医療従事者だけでなく、英語を学ぶことに興味のある方にも役立つでしょう。
日常コミュニケーションのためのトップ5フレーズ
- フェモラル動脈の穿刺（puncture）が重要です。
- アクセスの最適な場所は、大腿骨（femur）の頭の真ん中です。
- 超音波ガイドによるアクセスは、特に有効です。
- 患者の体重や皮下組織の厚さも考慮する必要があります。
- アクセスを誤ると、合併症のリスクが増加します。
ステップバイステップ・シャドーイングガイド
この動画の内容を効果的に理解し、英語力を向上させるためには、以下のステップを試してみてください。
- リスニング: まず、動画を視聴し、マゼン医師のトーンや発音に慣れましょう。最初は内容を理解することに集中し、メモを取る必要はありません。
- シャドーイング: 動画を繰り返し見ながら、マゼン医師の言葉をそのまま繰り返してみましょう。特に、アクセスや超音波ガイド（ultrasound guided）に関するフレーズに重点を置いてください。これにより、英語の音声とリズムを体得することができます。
- 発音練習: シャドーイングをしながら、自分の声を録音してみましょう。後で自分の発音を確認し、改善点を見つけることが重要です。
- キーワード復習: 動画に登場した重要なキーワードやフレーズをノートに書き出し、反復練習して覚えましょう。この「シャドースピーチ（shadow speech）」の方法で語彙が増え、日常会話でも使える表現が身につきます。
- ディスカッション: 英語を学べる仲間や教師と一緒にこの動画について話し合ってみてください。実際の意見交換を通じて、より深く内容を理解することができます。
これらのステップを実践することで、あなたの英語力が劇的に向上し、専門的な内容についても自信を持って話すことができるようになります。シャドーイングの技術を磨いて、英語学習をより充実したものにしましょう！
シャドーイングとは？英語上達に効果的な理由
シャドーイング（Shadowing）は、もともとプロの通訳者養成プログラムで開発された言語学習法で、多言語習得者として知られるDr. Alexander Arguelles によって広く普及されました。方法はシンプルですが非常に効果的：ネイティブスピーカーの英語を聞きながら、1〜2秒の遅延で声に出してすぐに繰り返す——まるで「影（shadow）」のように話者を追いかけます。文法ドリルや受動的なリスニングと異なり、シャドーイングは脳と口の筋肉が同時にリアルタイムで英語を処理・再現することを強制します。研究により、発音精度、抑揚、リズム、連音、リスニング力、そして会話の流暢さが大幅に向上することが確認されています。IELTSスピーキング対策や自然な英語コミュニケーションを目指す方に特におすすめです。