IVUS 血管内超声基础和临床.ppt

血管内超声基础和临床应用进展 IVUS培训 IVUS培训 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 RotatingElement DriveShaft Multi elementArray Therearetwotypesofimagingsystems Mechanical rotatingtransducer andElectronicArray IVUS培训 Highfrequencysoundwavesechooffvesselwallsandaresentbacktosystem Systemelectronicsprocessthesignal IVUS培训 A L A AxialResolutionL LateralResolution IVUS培训 Lowdynamicrange Highdynamicrange IVUS培训 Intimaldisease plaque isdenseandwillappear white Mediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound appearsdark Adventitiahas sheets ofcollagenthatreflectalotofultrasound appearswhite IVUS培训 IVUS培训 Calcium Brightechoes brighterthantheadventitia Obstructsthepenetrationofultrasound acousticshadowing onlytheleadingedgeisdetectedandthicknesscannotbedetermined Resultsinreverberations theoscillationofultrasoundbetweentransducerandcalciumcausingrepeating arcs IVUS培训 Calciumisquantifiedbymeasuringthe arc itencompassesCalciumisclassifiedbyitslocationwithintheplaqueSuperficialcalciumisclosertothelumenthantotheadventitiaDeepcalciumisclosertotheadventitiathantothelumen IVUS培训 FibroticPlaque Asbrightorbrighterthantheadventitia hyperechoic MajorityofatheroscleroticlesionsarefibroticVerydense fibrousplaquesmaycausesomuchacousticshadowingthattheycouldbemisclassifiedascalcified IVUS培训 SoftPlaque Notasbrightastheadventitia hypoechoic Soft referstothelowechogenicity generallyduetohighlipidcontentinamostlycellularlesion Reducedechodensitymayalsobedueto necroticzonewithinplaqueintramuralhemorrhagethrombus IVUS培训 VulnerablePlaque FibrousCap LipidCore IVUS培训 MixedPlaque IVUS培训 0 1 4mm ExampleofThrombus IVUS培训 ExamplesofThrombus IVUS培训 BasicMeasurements I Externalelasticmembrane EEM crosssectionalarea CSA totalarterialCSA media areatracingtheboundarybetweenthedarkmediaandthebrightadventitia i e theapparentouteredgeofthemediastripe LumenCSAMaxandminlumendiametersStentCSAMaxandminstentdiametersPlaque media P M CSA EEM LumenCSAinnon stentedlesions EEM stentCSAinstentedlesionsIntimalhyperplasiaCSA Stent LumenCSA IVUS培训 BasicMeasurements II Eccentricity maximum minimumP MthicknessPlaqueBurden cross sectionalnarrowingor plaquearea P M EEMCSARemodelingIndex Lesion ReferenceEEMCSAAreaStenosis Reference Lesion ReferenceLumenCSAArcofcalciumLesionlengthsmeasuredusingmotorizedtransducerpullback ideallyat0 5mm sec IVUS培训 Non stentedartery IVUS培训 StentedArtery IVUS培训 ProximalReference LesionSite DistalReference EEM Lumen P M MaxP MThickness MinP MThickness Ca IVUS培训 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 IVUS培训 In StentRestenosis In stentintimalhyperplasia IH oftenappearswithaverylowechogenicityCouldbelessechogenicthanthebloodspeckleAppropriatesystemsettingsarecriticaltovisualizeIH donot blackout center IVUS培训 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 LimitationsofCoronaryAngiography FocalDisease 50 Lesion 50 Lesion DiffuseDisease AngiogramSilhouette IVUS培训 AngiographicallySilentDisease In884nativecoronaryarteries theplaqueburdenintheangiographically normal referencesegmentwas51 13 MintzGS etal JAmCollCardiol1995 25 1479 1485 IVUS培训 CoronaryRemodelingHypothesis CompenatoryExpansionMaintainsConsistantLumen ExpansionOvercome LumenNarrows NormalVessel MinimalCAD ModerateCAD SevereCAD IVUS培训 Proximalreference Lesion Distalreference Intermediate remodeling Negative remodeling Positive remodeling Nishioka JACC1996 27 1571 1576 DicotomousClassificationofRemodeling IVUS培训 A B D E f f C F distal Lumen e b e b Lumen PositiveRemodeling NegativeRemodeling c c distal EEM EEM IVUS培训 LimitationsofCoronaryAngiography AngiogramSilhouette CoronaryCross section 75 25 IVUS培训 IrregularPlaque IrregularLumen A Cross section RAOView LAOView B C IVUS培训 IVUSEEMCSA 22 7mm2LumenCSA 16 6mm2Meanlumendiameter 4 6mm QCA9FguidingcatheterReferencediameter 3 12mm IVUS培训 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 IVUS培训 Fisheretal CCD1982 8 565 575 Comparisonbetweenpercentstenosisassessmentfromthequalitycontrollabvstheclinicalsite areaofthesquareisproportionaltothenumberofcaseswiththegivenreading Ofallthecoronarysegments theLMistheonewiththegreatestinter observervariabilityPoorinterobserveragreementintheangiographicassessmentofLMCAstenosisintheCASSstudy I PoorinterobserveragreementintheangiographicassessmentofLMCAstenosisintheCASSstudy II 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 IVUS培训 IVUS培训 Reference Lesion 10mm LumenCSA 18 3mm2Lumendiameter 5 0mm LumenCSA 3 6mm2Lumendiameter 1 3mm LumenCSA 11 9mm2Lumendiameter 3 5mm PatientwithnormalostialLMCAwhopreviouslyunderwentCABGforpresumedLMCAdisease Patientwithsevere butunrecognized distalLMCAstenosiswhowasreferredforPTCAofLAD SuggestedIVUSCriteriafora Significant LMCAStenosis MostIVUSLMCAstudiesshoweitherinsignificantdiseaseorcriticaldisease onlyaminorityrequirecarefulquantificationLumenCSA 6 0mm2orMLD 3 0mmaresuggestedcriteriaforasignificantLMCAstenosisThesumofthelumenareasofthetwodaughtervessels LADandLCX eachofwhichshouldbe4 0mm2 150 oftheparent LM ThesecorrelatedwithanabnormalFFR JastietalCirculation2004 110 2831 6 IVUS培训 IVUS培训 UnusualLesions IVUSClassificationofAngiographicAneurysms Of77angiographicaneurysms21 27 trueaneurysm3 4 pseudoaneurysm12 16 complexplaquesorunhealeddissections41 53 normalsegmentadjacenttooneormorestenoses Maeharaetal AmJCardiol2001 88 365 70 NormalSegmentwithAdjacentStenoses TrueAneurysm Pseudoaneurysm RupturedPlaque Proximal Distal Lesion MaxLD 3 5mm MaxLD 3 3mm StentsizingusingIVUS Referencesegmentdiseaseprovidesacushionforoversizing Thehighpredictivevalue 90 fortheminimumstentCSAinCypherstentssuggeststhatmostcausesofCypherstentfailurewillbe mechanical Predictorsofangiographicrestenosisin550ptswith670nativearterylesionstreatedwithCypherstents Angiographicrestenosis Angiographicrestenosis IVUSMSA mm2 IVUStotalstentlength mm Hongetal unpublished ComparisonofIVUS measuredminimumstent