血管内超声基础知识

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 isdenseandwillappear white Mediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound appearsdark Adventitiahas sheets ofcollagenthatreflectalotofultrasound appearswhite 南方会2008 南方会2008 Calcium Brightechoes brighterthantheadventitia Obstructsthepenetrationofultrasound acousticshadowing onlytheleadingedgeisdetectedandthicknesscannotbedetermined Resultsinreverberations theoscillationofultrasoundbetweentransducerandcalciumcausingrepeating arcs 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 media areatracingtheboundarybetweenthedarkmediaandthebrightadventitia 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 referencesegmentwas51 13 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 IVUSCriteriafora Significant Stenosis 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 SuggestedIVUSCriteriafora Significant LMCAStenosis MostIVUSLMCAstudiesshoweitherinsignificantdiseaseorcriticaldisease onlyaminorityrequirecarefulquantificationLumenCSA 6 0mm2orMLD 3 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 Cypherinyel