血管内超声基础知识.ppt

血管内超声基础知识阜外医院钱杰,南方会2008,血管内超声基础知识,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,南方会2008,RotatingElement,DriveShaft,Multi-elementArray,Therearetwotypesofimagingsystems:Mechanical(rotatingtransducer)andElectronicArray,南方会2008,Highfrequencysoundwavesechooffvesselwallsandaresentbacktosystem,Systemelectronicsprocessthesignal,南方会2008,Intimaldisease(plaque)isdenseandwillappearwhiteMediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound(appearsdark)Adventitiahassheetsofcollagenthatreflectalotofultrasound(appearswhite),南方会2008,南方会2008,Calcium,Brightechoes(brighterthantheadventitia)Obstructsthepenetrationofultrasound(acousticshadowing)onlytheleadingedgeisdetectedandthicknesscannotbedetermined.Resultsinreverberations-theoscillationofultrasoundbetweentransducerandcalciumcausingrepeatingarcs,南方会2008,Calciumisquantifiedbymeasuringthe“arc”itencompassesCalciumisclassifiedbyitslocationwithintheplaqueSuperficialcalciumisclosertothelumenthantotheadventitiaDeepcalciumisclosertotheadventitiathantothelumen,南方会2008,FibroticPlaque,Asbrightorbrighterthantheadventitia(hyperechoic)MajorityofatheroscleroticlesionsarefibroticVerydense,fibrousplaquesmaycausesomuchacousticshadowingthattheycouldbemisclassifiedascalcified,南方会2008,SoftPlaque,Notasbrightastheadventitia(hypoechoic)“Soft”referstothelowechogenicity,generallyduetohighlipidcontentinamostlycellularlesion.Reducedechodensitymayalsobedueto:necroticzonewithinplaqueintramuralhemorrhagethrombus,南方会2008,VulnerablePlaque,FibrousCap,LipidCore,南方会2008,MixedPlaque,南方会2008,0,1,4mm,ExampleofThrombus,南方会2008,BasicMeasurements(I),Externalelasticmembrane(EEM)crosssectionalarea(CSA)=totalarterialCSA=mediaareatracingtheboundarybetweenthedarkmediaandthebrightadventitia(i.e.,theapparentouteredgeofthemediastripe)LumenCSAMaxandminlumendiametersStentCSAMaxandminstentdiametersPlaque+media(P+M)CSA=EEM-LumenCSAinnon-stentedlesions=EEM-stentCSAinstentedlesionsIntimalhyperplasiaCSA=Stent-LumenCSA,南方会2008,BasicMeasurements(II),Eccentricity=maximum/minimumP+MthicknessPlaqueBurden(=cross-sectionalnarrowingor%plaquearea)=P+M/EEMCSARemodelingIndex=Lesion/ReferenceEEMCSAAreaStenosis=(Reference-Lesion)/ReferenceLumenCSAArcofcalciumLesionlengthsmeasuredusingmotorizedtransducerpullback,ideallyat0.5mm/sec,南方会2008,Non-stentedartery,南方会2008,StentedArtery,南方会2008,ProximalReference,LesionSite,DistalReference,EEM,Lumen,P+M,MaxP+MThickness,MinP+MThickness,Ca+,南方会2008,ProximalReference,LesionSite,DistalReference,EEMCSA=20.4LumenCSA=9.7Maxlumendiam=3.7MLD=3.1P+MCSA=10.7Eccentricity=1.0/0.3Plaqueburden=0.52ArcofCa=60,EEMCSA=21.6LumenCSA=4.5Maxlumendiam=32.8MLD=2.3P+MCSA=17.1Eccentricity=3.0/0.1Plaqueburden=0.79,EEMCSA=13.3LumenCSA=8.9Maxlumendiam=3.6MLD=3.0P+MCSA=4.4Eccentricity=0.6/0.2Plaqueburden=0.33,AverageReferenceEEMCSA=16.9RemodelingIndex=1.3AverageReferenceLumenCSA=9.3AreaStenosis=52%,南方会2008,In-StentRestenosis,In-stentintimalhyperplasia(IH)oftenappearswithaverylowechogenicityCouldbelessechogenicthanthebloodspeckleAppropriatesystemsettingsarecriticaltovisualizeIH(donot“blackout”center),南方会2008,血管内超声基础知识,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,南方会2008,LimitationsofCoronaryAngiography,FocalDisease,50%Lesion,50%Lesion,DiffuseDisease,AngiogramSilhouette,南方会2008,AngiographicallySilentDisease,In884nativecoronaryarteries,theplaqueburdenintheangiographically“normal”referencesegmentwas5113%,MintzGS,etal.JAmCollCardiol1995;25:1479-1485,南方会2008,CoronaryRemodelingHypothesis,CompenatoryExpansionMaintainsConsistantLumen,ExpansionOvercome:LumenNarrows,NormalVessel,MinimalCAD,ModerateCAD,SevereCAD,南方会2008,Proximalreference,Lesion,Distalreference,Intermediate,remodeling,Negative,remodeling,Positive,remodeling,Nishioka.JACC1996;27:1571-1576,DicotomousClassificationofRemodeling,南方会2008,IrregularPlaque/IrregularLumen,A,Cross-section,RAOView,LAOView,B,C,南方会2008,IVUSEEMCSA=22.7mm2LumenCSA=16.6mm2Meanlumendiameter=4.6mm,QCA9FguidingcatheterReferencediameter=3.12mm,南方会2008,血管内超声基础知识,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,南方会2008,ValidationofIVUSAssessmentofIschemiaProducingStenosis(DopplerFloWireandSPECT),Diagnosticaccuracy=92%.Abizaidetal,AJC1998;82:42-8,Diagnosticaccuracy=93%.Nishiokaetal,JACC1999;33:1870-8,南方会2008,IVUSCriteriaforaSignificantStenosis,BasedonthestudiescomparingIVUStoflowwire,pressurewire,orSPECTthalliumandbasedonstudieswithclinicaloutcome-mostfeelthatalumenarealessthan4.0mm2inaproximalepicardialarteryexcludingtheLeftMainisaflowlimitingstenosis,南方会2008,PoorinterobserveragreementintheangiographicassessmentofLMCAstenosisintheCASSstudyII,(Cameronetal.Circulation1983;68:484-489),FivegradesofLMseverity,1:0-24%DS2:25-49%DS3:50-74%DS4:75-89%DS5:90-100%DS,#ofgradesofdifferenceinassessmentofLMseverity,0:nodifference+1or-1:1gradedifference+2or-2:2gradesofdifference+3or-3:3gradesofdifference+4or-4:4gradesofdifference,ClinicalsitevsQualitycontrol,ClinicalsitevsStudyGroup,StudyGroupvsQualitycontrol,南方会2008,Reference,Lesion,10mm,LumenCSA=18.3mm2Lumendiameter=5.0mm,LumenCSA=3.6mm2Lumendiameter=1.3mm,LumenCSA=11.9mm2Lumendiameter=3.5mm,PatientwithnormalostialLMCAwhopreviouslyunderwentCABGforpresumedLMCAdisease,Patientwithsevere,butunrecognized,distalLMCAstenosiswhowasreferredforPTCAofLAD,南方会2008,SuggestedIVUSCriteriaforaSignificantLMCAStenosis,MostIVUSLMCAstudiesshoweitherinsignificantdiseaseorcriticaldisease,onlyaminorityrequirecarefulquantificationLumenCSA6.0mm2orMLD3.0mmaresuggestedcriteriaforasignificantLMCAstenosisThesumofthelumenareasofthetwodaughtervessels(LADandLCX,eachofwhichshouldbe4.0mm2)=150%oftheparent(LM)ThesecorrelatedwithanabnormalFFR(JastietalCirculation2004;110:2831-6),南方会2008,UnusualLesions:IVUSClassificationofAngiographicAneurysms,Of77angiographicaneurysms21(27%)trueaneurysm3(4%)pseudoaneurysm12(16%)complexplaquesorunhealeddissections41(53%)normalsegmentadjacenttooneormorestenoses,(Maeharaetal.AmJCardiol2001;88:365-70),南方会2008,Proximal,Distal,Lesion,MaxLD=3.5mm,MaxLD=3.3mm,StentsizingusingIVUS,南方会2008,Thehighpredictivevalue(90%)fortheminimumstentCSAinCypherstentssuggeststhatmostcausesofCypherstentfailurewillbe“mechanical”,南方会2008,Predictorsofangiographicrestenosisin550ptswith670nativearterylesionstreatedwithCypherstents,Angiographicrestenosis(%),Angiographicrestenosis(%),IVUSMSA(mm2),IVUStotalstentlength(mm),(Hongetal.unpublished),南方会2008,ComparisonofIVUS-measuredminimumstentdiameter(MSD)andminimumstentarea(MSA)withthepredictedmeasurementsfromCordis(Cypherinyell