冠状动脉造影abc课件

冠心病介入诊疗-ABC 1929年,德国医生Wenner Forssmann在自己身上进行了人类首例 心导管检查术. 他将导管经左肘前静脉,锁骨下静脉,上腔静脉 送入右心房,并拍了医学史上第一张右心导管胸片,从此揭开了 介入心脏病学的序幕. 1959年Mason Sones 利用特制的尖端呈弧形的造影导管,经肱 动脉送入主动脉根部进行主动脉造影,无意中将造影剂直接注 入右冠状动脉内使其清晰显影, 这一偶然事件开创了冠脉介入诊断技术的新纪元 冠脉造影冠脉造影5050余年的历程余年的历程! ! CA introduced by F. Mason Sones, Jr, MD (CA introduced by F. Mason Sones, Jr, MD (首次冠脉造影首次冠脉造影) ) The first human studies- severity and extent of CAD (The first human studies- severity and extent of CAD (首个人体研究首个人体研究) ) Earliest natural history studies of proven CAD Earliest natural history studies of proven CAD Dynamic visualization of LV performance (Dynamic visualization of LV performance (左室造影左室造影) ) Demonstration of prompt and complete revascularization by CABGDemonstration of prompt and complete revascularization by CABG Refinement of natural history studies of unoperated CAD patients Refinement of natural history studies of unoperated CAD patients Discovery of the benefit of CABG vs. Med Rx in subsets of patients Discovery of the benefit of CABG vs. Med Rx in subsets of patients Delineation of coronary vasospasm and PrinzmetalDelineation of coronary vasospasm and Prinzmetal s angina(s angina(冠脉冠脉痉挛痉挛痉挛痉挛) ) Significance of coronary pathoanatomy (ulceration, thrombus, Significance of coronary pathoanatomy (ulceration, thrombus, dissection, aneurysm, muscle bridge, collateral vessels) dissection, aneurysm, muscle bridge, collateral vessels) Introduction of PTCA and delineation of restenosis (PTCAIntroduction of PTCA and delineation of restenosis (PTCA及再狭窄及再狭窄) ) First angiographic evidence of clot lysis in a coronary vesselFirst angiographic evidence of clot lysis in a coronary vessel 1950s 1960s 1970s Ryan Circulation 2002, 106:752-756 冠脉造影冠脉造影5050余年的历程余年的历程! ! Thrombolytic era, with the demonstration of spontaneous fibrinolysis Thrombolytic era, with the demonstration of spontaneous fibrinolysis during 24 hrs of acute occlusions (during 24 hrs of acute occlusions (心梗心梗2424小小时时时时内的内的血栓血栓自溶自溶) ) Plaque regression studies uncovering the clinical benefits of statin Plaque regression studies uncovering the clinical benefits of statin therapy (therapy (他汀治他汀治疗疗疗疗斑斑块块块块消褪消褪) ) Delineation of the pathogenesis of AMI from studies outlining Delineation of the pathogenesis of AMI from studies outlining angiographic progression to MI (AMIangiographic progression to MI (AMI的的发发发发病机制病机制) ) Estimates of coronary flow using TFG and TFCEstimates of coronary flow using TFG and TFC Comparisons of PCI vs CABG for revascularization outcomesComparisons of PCI vs CABG for revascularization outcomes Stents era Stents era Myocardial blush (Myocardial blush (心肌染色分心肌染色分级级级级) ) Brachytherapy, late stent thrombosis, and pharmocotherapy Brachytherapy, late stent thrombosis, and pharmocotherapy The coronary catheter and newer imaging devices (intravascular The coronary catheter and newer imaging devices (intravascular ultrasound, MRI)ultrasound, MRI) 1980s 1990s Ryan Circulation 2002, 106:752-756 2013 冠脉造影冠脉造影 股动脉及桡动脉路径股动脉及桡动脉路径 股神经 股总动 脉 股静脉 穿刺位置 股骨头 腹股沟韧带 尺动脉 桡动 脉 肱动脉 解剖学解剖学 桡动桡动 脉 掌浅弓 尺动动脉 Allen Allen 试验试验试验试验 Allen Allen 试验试验试验试验解解读读读读 AssementAssement of ulnar arch by of ulnar arch by oxymetryoxymetry n nAllenAllen s test is subjective and difficult to s test is subjective and difficult to interpretinterpret n nBarbeauBarbeau score score Barbeau. G et al; Am Heart J 2004;147:48993 2 min Barbeau. G et al; Am Heart J 2004;147:48993 NO BarbeauBarbeau score score 冠脉造影冠脉造影 导管导管 Judkins Amplatz Tiger 导导管 JR4 导导管 冠脉解剖学冠脉解剖学 左主干(LM) 左前降支(LAD) 对角支(D1, D2) 间隔支(septal) LAD D1 Septal D2 LMS RCA PLV INF PDA AM 左前降支左前降支 Radiographics 2007;27:1569-1582 Radiographics 2007;27:1569-1582 右冠状右冠状动动动动脉脉 Marginal branch Conus branch Marginal branch 回旋支回旋支 回旋支 (Cx) 钝缘支 (OM1, OM2) OM1 CX OM2 LAD Radiographics 2007;27:1569-1582 回旋支回旋支 OM OM LMS CX CX OM Radiographics 2007;27:1569-1582 中中间间间间支支 IM CX LMS 右右优势优势优势优势 : : This occurs when the This occurs when the descending, inferior, and descending, inferior, and posterior branches all arise posterior branches all arise from the RCA.from the RCA. 均衡型均衡型 : : This occurs when only the This occurs when only the descending branch arises descending branch arises from the RCA, while the from the RCA, while the inferior and posterior inferior and posterior branches arise from the CX.branches arise from the CX. 左左优势优势优势优势 : : This occurs when all three This occurs when all three branches arise from the CX.branches arise from the CX. 冠脉冠脉优势优势优势优势型型 后侧支(PL) 后降支(PD) 冠脉起源异常冠脉起源异常 左主干起源 于右冠窦 http:/www.radiologyassistant.nl/en/48275120e2ed5 心肌心肌桥桥桥桥 Myocardial bridge in LAD http:/www.radiologyassistant.nl/en/48275120e2ed5 A myocardial bridge occurs when one of the coronary arteries tunnels through the myocardium rather than resting on top of the myocardium 冠脉造影提供的信息冠脉造影提供的信息 定量冠脉造影分析定量冠脉造影分析 冠脉血流冠脉血流 心肌灌注心肌灌注 其他特性其他特性: : 钙钙钙钙化化 血栓血栓 溃疡溃疡溃疡溃疡 夹层夹层夹层夹层 动动动动脉瘤脉瘤 钙化 定量冠脉造影分析定量冠脉造影分析(QCA)(QCA) 1 1近端参考血管直径近端参考血管直径: : 2. 2. 最小直径最小直径: : 3. 3. 远远远远端参考血管直径端参考血管直径: : 4. 4. 病病变长变长变长变长度度: : 直径狭窄直径狭窄: : 1 2 3 4 病病变变变变特征描述特征描述 偏心偏心: : The plaque is twice as large on The plaque is twice as large on one side of the arterial border one side of the arterial border compared with the other. compared with the other. 钙钙钙钙化化: Readily apparent densities : Readily apparent densities noted within the apparent vascular noted within the apparent vascular wall at the site of the stenosis.wall at the site of the stenosis. 弥漫弥漫: : Lesion is 20 mm in length. Lesion is 20 mm in length. 分叉分叉: : Atherosclerotic plaque involves Atherosclerotic plaque involves the origin of two separate arteries. the origin of two separate arteries. 开口开口: : Lesion beginning within 3-5 mm Lesion beginning within 3-5 mm of the origin of a major of the origin of a major epicardialepicardial artery.artery. Bifurcation Ostial TIMI TIMI 血流分血流分级级级级 TIMI Flow grade:TIMI Flow grade: Classification of TFGClassification of TFG Grade 0Grade 0, , no perfusion no perfusion Grade 1Grade 1, , penetration penetration without perfusion without perfusion Grade 2Grade 2, partial perfusion , partial perfusion Grade 3Grade 3, , complete complete perfusion perfusion TFG0TFG1TFG2TFG3 TIMI TIMI 计帧计帧计帧计帧 TIMI Frame Count:TIMI Frame Count: Gibson C M et al. Circulation 1999;99:1945-1950 Gibson et al found a mean corrected TFC (cTFC) for normal coronary arteries of 21 3.1 frames, yielding a 95% confidence interval for normal flow of (15, 27) frames. The Frame Count Reserve (FCR) can be calculated by dividing basal by hyperaemic TFC. The Frame Count Velocity (FCV) can be calculated by multiplying the length of the coronary artery by the acquisition rate (12.5, 25, 30 f/s) and dividing by the TFC. TIMI TIMI 心肌灌注分心肌灌注分级级级级 TIMI Myocardial Perfusion Grade:TIMI Myocardial Perfusion Grade: TMPG 0TMPG 0: : Failure of dye to enter the Failure of dye to enter the microvasculature.microvasculature. TMPG 1TMPG 1: : Dye slowly enters but fails to Dye slowly enters but fails to exit the microvasculature.exit the microvasculature. TMPG 2TMPG 2: : Delayed entry and exit of Delayed entry and exit of dye from the microvasculature.dye from the microvasculature. TMPG 3TMPG 3: : Normal entry and exit of dye Normal entry and exit of dye from the microvasculature.from the microvasculature. Gibson et al. Circulation 2000; 101:125-130 28 | MDT Confidential UC201204429EE 直接直接PCIPCI后，虽然心外膜冠状动脉血流率高，但再灌注未成功后，虽然心外膜冠状动脉血流率高，但再灌注未成功 Brener SJ et al. Circ CV Interv. 2012;5:563-9 Farkouh ME et al. Circ CV Interv. 2013;6:216-23 心肌灌注分级TIMI血流 ST段回落 29 | MDT Confidential UC201204429EE 镜下远端栓子和无复流镜下远端栓子和无复流 TIMI 3 级血流 无微血管灌注 Henriques JPS et al. EHJ 2002;23:1112-7 血栓分血栓分级级级级 Grade 0Grade 0: : No cine-angiographic characteristics of thrombus present. No cine-angiographic characteristics of thrombus present. Grade 1:Grade 1: Hazy, possible thrombus present. Angiography Hazy, possible thrombus present. Angiography demonstrates characteristics such as reduced contrast density, demonstrates characteristics such as reduced contrast density, haziness, irregular lesion contour, or a smooth convex “meniscus“ at haziness, irregular lesion contour, or a smooth convex “meniscus“ at the site of total occlusion suggestive but not diagnostic of thrombus.the site of total occlusion suggestive but not diagnostic of thrombus. Grade 2:Grade 2: Thrombus present small size: Definite thrombus with Thrombus present small size: Definite thrombus with greatest dimensions less than or equal to 1/2 vessel diameter.greatest dimensions less than or equal to 1/2 vessel diameter. Grade 3:Grade 3: Thrombus present moderate size: Definite thrombus but Thrombus present moderate size: Definite thrombus but with greatest linear dimension greater than 1/2 but less than 2 vessel with greatest linear dimension greater than 1/2 but less than 2 vessel diameters.diameters. Grade 4:Grade 4: Thrombus present large size: As in Grade 3 but with the Thrombus present large size: As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameters.largest dimension greater than or equal to 2 vessel diameters. Grade 5Grade 5: : Recent total occlusion, can involve some collateralization Recent total occlusion, can involve some collateralization but usually does not involve extensive collateralization, tends to have but usually does not involve extensive collateralization, tends to have a a “ “beakbeak” ” shape and a hazy edge or appearance of distinct thrombus. shape and a hazy edge or appearance of distinct thrombus. Grade 6:Grade 6: Chronic total occlusion, usually involving Chronic total occlusion, usually involving extensiveextensive collateralization, tends to have distinct, blunt cutoff/edge and will collateralization, tends to have distinct, blunt cutoff/edge and will generally clot up to the nearest proximal side branch.generally clot up to the nearest proximal side branch. Gibson CM et al. Circulation. 2001;103:2550-2554 Grade 5 thrombus Grade