IVUS 血管内超声基础和临床ppt课件

The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York 血管内超声基础和临床应用进展 IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York 血管内超声基础和进展 一、 血管内超声基础 二、血管内超声和冠脉造影的关系 三、主要适应症 四、什么是 VH IVUS 培训 Rotating Element Drive Shaft Multi-element Array The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York There are two types of imaging systems: Mechanical (rotating transducer) and Electronic Array IVUS 培训 High frequency sound waves echo off vessel walls and are sent back to system System electronics process the signal The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 A L A = Axial Resolution L= Lateral Resolution The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 Low dynamic range High dynamic range The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 Intimal disease (plaque) is dense and will appear white Media is made of homogeneous smooth muscle cells and does not reflect ultrasound (appears dark) Adventitia has sheets of collagen that reflect a lot of ultrasound (appears white) The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Calcium Bright echoes (brighter than the adventitia) Obstructs the penetration of ultrasound (acoustic shadowing) only the leading edge is detected and thickness cannot be determined. Results in reverberations - the oscillation of ultrasound between transducer and calcium causing repeating arcs IVUS 培训 80 Superficial Deep Deep Calcium is quantified by measuring the “arc” it encompasses Calcium is classified by its location within the plaque Superficial calcium is closer to the lumen than to the adventitia Deep calcium is closer to the adventitia than to the lumen The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Fibrotic Plaque As bright or brighter than the adventitia (hyperechoic) Majority of atherosclerotic lesions are fibrotic Very dense, fibrous plaques may cause so much acoustic shadowing that they could be misclassified as calcified IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Soft Plaque Not as bright as the adventitia (hypoechoic) “Soft” refers to the low echogenicity, generally due to high lipid content in a mostly cellular lesion. Reduced echodensity may also be due to: necrotic zone within plaque intramural hemorrhage thrombus IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Vulnerable Plaque Fibrous Cap Lipid Core IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Mixed Plaque IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York 0 1 4mm Example of Thrombus IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Examples of Thrombus IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Basic Measurements (I) External elastic membrane (EEM) cross sectional area (CSA) = total arterial CSA = media area tracing the boundary between the dark media and the bright adventitia (i.e., the apparent outer edge of the media stripe) Lumen CSA Max and min lumen diameters Stent CSA Max and min stent diameters Plaque+media (P+M) CSA = EEM - Lumen CSA in non-stented lesions = EEM - stent CSA in stented lesions Intimal hyperplasia CSA = Stent - Lumen CSA IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Basic Measurements (II) Eccentricity = maximum/minimum P+M thickness Plaque Burden (=cross-sectional narrowing or %plaque area) = P+M/EEM CSA Remodeling Index = Lesion/Reference EEM CSA Area Stenosis = (Reference - Lesion)/Reference Lumen CSA Arc of calcium Lesion lengths measured using motorized transducer pullback, ideally at 0.5 mm/sec IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Non-stented artery EEMGuidewires IVUS catheter Plaque+media Lumen IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Stented Artery EEM Lumen Stent Guidewire IVUS catheter Plaque+mediaIntimal hyperplasia IVUS 培训 Proximal Reference Lesion Site Distal Reference EEM Lumen P+M Max P+M Thickness Min P+M Thickness Ca+ The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 0 3mm 12mm Proximal Reference Lesion Site Distal Reference EEM CSA = 20.4 Lumen CSA = 9.7 Max lumen diam = 3.7 MLD = 3.1 P+M CSA = 10.7 Eccentricity = 1.0/0.3 Plaque burden = 0.52 Arc of Ca = 60 EEM CSA = 21.6 Lumen CSA = 4.5 Max lumen diam = 32.8 MLD = 2.3 P+M CSA = 17.1 Eccentricity = 3.0/0.1 Plaque burden = 0.79 EEM CSA = 13.3 Lumen CSA = 8.9 Max lumen diam = 3.6 MLD = 3.0 P+M CSA = 4.4 Eccentricity = 0.6/0.2 Plaque burden = 0.33 Average Reference EEM CSA = 16.9 Remodeling Index = 1.3 Average Reference Lumen CSA = 9.3 Area Stenosis = 52% The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York In-Stent Restenosis In-stent intimal hyperplasia (IH) often appears with a very low echogenicity Could be less echogenic than the blood speckle Appropriate system settings are critical to visualize IH (do not “black out” center) IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York 血管内超声基础和进展 一、血管内超声基础 二、 血管内超声和冠脉造影的关系 三、主要适应症 四、什么是 VH IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Limitations of Coronary Angiography Focal Disease 50% Lesion 50% LesionDiffuse Disease Angiogram Silhouette IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Angiographically Silent Disease In 884 native coronary arteries, the plaque burden in the angiographically “normal” reference segment was 5113% Mintz GS, et al. J Am Coll Cardiol 1995;25:1479-1485 IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Coronary Remodeling Hypothesis Compenatory Expansion Maintains Consistant Lumen Expansion Overcome: Lumen Narrows Normal Vessel Minimal CAD Moderate CAD Severe CAD IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Proximal reference Lesion Distal reference Intermediate remodeling Negative remodeling Positive remodeling Nishioka. JACC 1996; 27:1571-1576 Dicotomous Classification of Remodeling IVUS 培训 A B D E f f C F distal Lumen e b e b Lumen Positive Remodeling Negative Remodeling c c distal EEM EEM IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Limitations of Coronary Angiography Angiogram Silhouette Coronary Cross-section 75% 25% IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Irregular Plaque / Irregular Lumen A Cross-section RAO View LAO View B C IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York IVUS EEM CSA = 22.7mm2 Lumen CSA = 16.6mm2 Mean lumen diameter = 4.6mm QCA 9F guiding catheter Reference diameter = 3.12mm IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York 血管内超声基础和进展 一、血管内超声基础 二、血管内超声和冠脉造影的关系 三、 主要适应症 四、什么是 VH IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 (Fisher et al. CCD 1982;8:565-575) Comparison between percent stenosis assessment from the quality control lab vs the clinical site *area of the square is proportional to the number of cases with the given reading QC lab Clinical site 100 0 1000 Of all the coronary segments, the LM is the one with the greatest inter-observer variability Poor interobserver agreement in the angiographic assessment of LMCA stenosis in the CASS study - I The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Poor interobserver agreement in the angiographic assessment of LMCA stenosis in the CASS study - II (Cameron et al. Circulation 1983;68:484-489) Five grades of LM severity 1: 0-24% DS 2: 25-49% DS 3: 50-74% DS 4: 75-89% DS 5: 90-100%DS # of grades of difference in assessment of LM severity 0: no difference +1 or -1: 1 grade difference +2 or -2: 2 grades of difference +3 or -3: 3 grades of difference +4 or -4: 4 grades of difference Clinical site vs Quality control Clinical site vs Study Group Study Group vs Quality control IVUS 培训 The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New YorkIVUS 培训 Reference Lesion10 mm Lumen CSA = 18.3mm2 Lumen diameter = 5.0mm Lumen CSA = 3.6mm2 Lumen diameter = 1.3mm Lumen CSA = 11.9mm2 Lumen diameter = 3.5mm Patient with normal ostial LMCA who previously underwent CABG for presumed LMCA disease Patient with severe, but unrecognized, distal LMCA stenosis who was referred for PTCA of LAD The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Suggested IVUS Criteria for a Significant LMCA Stenosis Most IVUS LMCA studies show either insignificant disease or critical disease, only a minority require careful quantification Lumen CSA 4.0mm2 (%) Cypher 5.0* sensitivity specificity 0 10 20 30 40 50 60 70 80 90 100 3.54.04.55.05.56.0 7.07.5 8.08.5 F/U MLA 4.0mm2 (%) Bare Metal Stents 6.5*Minimum stent area (mm2) Minimum stent area (mm2) (Sonoda et al. J Am Coll Cardiol 2004;43:1959-63) *predictive value=56% *predictive value=90% The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Predictors of angiographic restenosis in 550 pts with 670 native artery lesions treated with Cypher stents 0 20 40 60 80 100 0 20 40 60 80 100 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 Angiographic restenosis (%)Angiographic restenosis (%) IVUS MSA (mm2) 10152025303540455560657075 IVUS total stent length (mm) 40mm 17.7% 8.6%(Hong et al. unpublished) The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Comparison of IVUS-measured minimum stent diameter (MSD) and minimum stent area (MSA) with the predicted measurements from Cordis (Cypher in yellow, n=133) and BSC (Taxus in red, n=67). DES achieve an average of only 75% of the predicted MSD (66% of MSA) IVUS Measured MSA (mm 2) Predicted MSA (mm2) IVUS Measured MSD (mm) Predicted MSD (mm) 24% The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Peri-Stent Haziness: Double Lumen The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Peri-Stent Haziness: Plaque Burden Two Overlapping Stents Hazy Segment The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Peri-Stent Haziness: Calcification Stent The Cardiovascular Research Foundation Lenox Hill Heart and Vascular Institute of New York Peri-Stent Injury: Plaque Tear Ultrasound Sit