IVUS基础—阜外医院钱杰ppt课件.ppt

血管内超声基础和临床应用进展阜外医院钱杰,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)isdenseandwillappearwhiteMediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound(appearsdark)Adventitiahassheetsofcollagenthatreflectalotofultrasound(appearswhite),IVUS培训,IVUS培训,Calcium,Brightechoes(brighterthantheadventitia)Obstructsthepenetrationofultrasound(acousticshadowing)onlytheleadingedgeisdetectedandthicknesscannotbedetermined.Resultsinreverberations-theoscillationofultrasoundbetweentransducerandcalciumcausingrepeatingarcs,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=mediaareatracingtheboundarybetweenthedarkmediaandthebrightadventitia(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”referencesegmentwas5113%,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,SuggestedIVUSCriteriaforaSignificantLMCAStenosis,MostIVUSLMCAstudiesshoweitherinsignificantdiseaseorcriticaldisease,onlyaminorityrequirecarefulquantificationLumenCSA6.0mm2orMLD3.0mmaresuggestedcriteriaforasignificantLMCAstenosisThesumofthelumenareasofthetwodaughtervessels(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