IVUS-血管内超声基础和临床课件.ppt

1、The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New York血管内超声基础和临床应用进展血管内超声基础和临床应用进展IVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New

2、 York血管内超声基础和进展血管内超声基础和进展一、一、血管内超声基础二、血管内超声和冠脉造影的关系二、血管内超声和冠脉造影的关系三、主要适应症三、主要适应症四、什么是四、什么是VHIVUS 培训 Rotating ElementDrive ShaftMulti-element ArrayThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkThere are two types of imaging systems:Mechanical(rotating transduc

3、er)and Electronic ArrayIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 ALThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 Low dynamic rangeHigh dynamic rangeThe CardiovascularResearch FoundationLenox

4、 Hill Heart and VascularInstitute of New YorkIVUS 培训 Intimal disease(plaque)is dense and will appear whiteMedia is made of homogeneous smooth muscle cells and does not reflect ultrasound(appears dark)Adventitia has sheets of collagen that reflect a lot of ultrasound(appears white)The CardiovascularR

5、esearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkCalciumBright echoes(brighter than the adv

6、entitia)Obstructs the penetration of ultrasound(acoustic shadowing)only the leading edge is detected and thickness cannot be determined.Results in reverberations-the oscillation of ultrasound between transducer and calcium causing repeating arcsIVUS 培训 The CardiovascularResearch FoundationLenox Hill

7、 Heart and VascularInstitute of New YorkIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkFibrotic PlaqueAs bright or brighter than the adventitia(hyperechoic)Majority of atherosclerotic lesions are fibroticVery dense,fibrous plaques may cause so much aco

8、ustic shadowing that they could be misclassified as calcifiedIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkSoft PlaqueNot as bright as the adventitia(hypoechoic)“Soft”refers to the low echogenicity,generally due to high lipid content in a mostly cellu

9、lar lesion.Reduced echodensity may also be due to:necrotic zone within plaqueintramural hemorrhagethrombusIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkVulnerable PlaqueIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitut

10、e of New YorkMixed PlaqueIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkExample of ThrombusIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkExamples of ThrombusIVUS 培训 The CardiovascularResearch FoundationL

11、enox Hill Heart and VascularInstitute of New YorkBasic Measurements(I)External elastic membrane(EEM)cross sectional area(CSA)=total arterial CSA =media areatracing the boundary between the dark media and thebright adventitia(i.e.,the apparent outer edge of the media stripe)Lumen CSAMax and min lumen

12、 diametersStent CSA Max and min stent diametersPlaque+media(P+M)CSA=EEM-Lumen CSA in non-stented lesions=EEM-stent CSA in stented lesionsIntimal hyperplasia CSA=Stent-Lumen CSAIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkBasic Measurements(II)Eccentr

13、icity=maximum/minimum P+M thicknessPlaque Burden(=cross-sectional narrowing or%plaque area)=P+M/EEM CSARemodeling Index=Lesion/Reference EEM CSAArea Stenosis=(Reference-Lesion)/Reference Lumen CSAArc of calciumLesion lengths measured using motorized transducer pullback,ideally at 0.5 mm/secIVUS 培训 T

14、he CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkNon-stented arteryEEMGuidewiresIVUS catheterPlaque+mediaLumenIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkStented ArteryEEMLumenStentGuidewireIVUS catheterPlaque+me

15、diaIntimal hyperplasiaIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of N

16、ew YorkIn-Stent RestenosisIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New York血管内超声基础和进展血管内超声基础和进展一、血管内超声基础一、血管内超声基础二、二、血管内超声和冠脉造影的关系三、主要适应症三、主要适应症四、什么是四、什么是VHIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkLim

17、itations of Coronary AngiographyFocal Disease50%Lesion50%LesionDiffuse DiseaseAngiogram SilhouetteIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkAngiographically Silent DiseaseIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularIn

18、stitute of New YorkCoronary Remodeling HypothesisCompenatory ExpansionMaintains Consistant LumenExpansionOvercome:Lumen NarrowsNormal VesselMinimal CADModerate CADSevere CADIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkDicotomous Classification of Rem

19、odelingIVUS 培训 ABDEffCFdistalLumenebebLumenccdistalIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkLimitations of Coronary AngiographyAngiogram SilhouetteCoronary Cross-section75%25%IVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and Vascu

20、larInstitute of New YorkIrregular Plaque/Irregular LumenACross-sectionRAO ViewLAO ViewBCIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUSEEM CSA=22.7mm2Lumen CSA=16.6mm2Mean lumen diameter=4.6mmQCA9F guiding catheterReference diameter=3.12mmIVUS 培训 T

21、he CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New York血管内超声基础和进展血管内超声基础和进展一、血管内超声基础一、血管内超声基础二、血管内超声和冠脉造影的关系二、血管内超声和冠脉造影的关系三、三、主要适应症四、什么是四、什么是VHIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 (Fisher et al.CCD 1982

22、;8:565-575)QC labClinical site10001000Of all the coronary segments,the LM is the one with the greatest inter-observer variability Poor interobserver agreement in the angiographic assessment of LMCA stenosis in the CASS study-IThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitut

23、e of New YorkPoor interobserver agreement in the angiographic assessment of LMCA stenosis in the CASS study-II(Cameron et al.Circulation 1983;68:484-489)020406080100-3-2-10+1+2+3+4Five grades of LM severity1:0-24%DS2:25-49%DS3:50-74%DS4:75-89%DS5:90-100%DS#of grades of difference in assessment of LM

24、 severity 0:no difference+1 or-1:1 grade difference+2 or-2:2 grades of difference+3 or-3:3 grades of difference+4 or-4:4 grades of difference020406080100-3-2-10+1+2+3+4020406080100-2-10+1+2IVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 Referenc

25、eLesion10 mmThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkSuggested IVUS Criteria for a Significant LMCA StenosisMost IVUS LMCA studies show either insignificant disease or critical disease,only a minority require careful quantificationLumen CSA 6.0mm2 or MLD

26、 3.0mm are suggested criteria for a significant LMCA stenosisThe sum of the lumen areas of the two daughter vessels(LAD and LCX,each of which should be 4.0mm2)=150%of the parent(LM)These correlated with an abnormal FFR(Jasti et al Circulation 2004;110:2831-6)IVUS 培训 The CardiovascularResearch Founda

27、tionLenox Hill Heart and VascularInstitute of New YorkIVUS 培训 Unusual Lesions:IVUS Classification of Angiographic AneurysmsOf 77 angiographic aneurysms 21(27%)true aneurysm3(4%)pseudoaneurysm12(16%)complex plaques or unhealed dissections41(53%)normal segment adjacent to one or more stenosesTrueAneur

28、ysmPSAComplexPlaqueNormal Site withAdjacent StenosesNo prior PCI100626Prior PCI113615018mmThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkThe high predictive value(90%)for the minimum stent CSA in Cypher stents suggests that most causes of Cypher stent failure

29、will be“mechanical”(Sonoda et al.J Am Coll Cardiol 2004;43:1959-63)The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkPredictors of angiographic restenosis in 550 pts with 670 native artery lesions treated with Cypher stents40mm17.7%8.6%The CardiovascularResearch

30、FoundationLenox Hill Heart and VascularInstitute of New York0246810121402468101214IVUS Measured MSA(mm2)Predicted MSA(mm2)012345012345IVUS Measured MSD(mm)Predicted MSD(mm)The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkPeri-Stent Haziness:Double LumenThe Cardi

31、ovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkPeri-Stent Haziness:Plaque BurdenTwoOverlappingStentsHazySegmentThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkPeri-Stent Haziness:CalcificationStentThe CardiovascularResearch Founda

32、tionLenox Hill Heart and VascularInstitute of New YorkPeri-Stent Injury:Plaque TearUltrasoundSiteStentThe CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New York何时采用何时采用IVUS IVUS 以达到最佳的以达到最佳的 DES DES 置入置入高危患者亚组高危患者亚组肾功能不全肾功能不全SATSAT双重抗血小板药物使用的局限性双重抗血小板药物使用的局限性SATSAT糖尿病糖尿病

33、ISR,SATISR,SAT左心室功能差左心室功能差SATSAT高危病变亚组高危病变亚组分叉病变分叉病变ISR,SATISR,SAT开口病变开口病变ISRISR小血管小血管ISRISR长病变长病变ISRISR治疗支架内再狭窄（治疗支架内再狭窄（ISRISR）ISRISR左主干病变左主干病变 (特别是具有上述矛盾的结果和危险因素特别是具有上述矛盾的结果和危险因素)The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New York血管内超声基础和进展血管内超声基础和进展一、血管内超声基础一、

34、血管内超声基础二、血管内超声和冠脉造影的关系二、血管内超声和冠脉造影的关系三、主要适应症三、主要适应症四、四、什么是VHIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkVirtual HistologyTM VolcanoIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkVirtual HistologyTM Vol

35、canoFIBROTICFIBRO-LIPIDCALCIFICLIPID COREMEDIALegendMa xP -2 5.05Typ e:C olla ge n#of RO Is:2 6Int -28.65#of RO Is:3 1Int -14.8Typ e:C olla ge n#of RO Is:5F at Ma xP 21.04 5Typ e:C olla ge n#of RO Is:1 7MB F -6 5.0 9#of RO Is:2 7Int -4.1 95Typ e:C olla ge n#of RO Is:5MB F -6 5.0 9#of RO Is:1 1F at M

36、a xP 30.03#of RO Is:3 8Ma xP -1 6.09 5Typ e:C olla ge n#of RO Is:6F at Ma xP 34.27 5Typ e:N ecr otic#of RO Is:6MB F -6 6.6 5Typ e:C olla ge n#of RO Is:5Ma xP -1 2.14 5Typ e:Fib ro-Lipidic#of RO Is:5F at Ma xP 34.27 5#of RO Is:1 5Ma xP -9.9 15#of RO Is:2 1F at Ma xP 35.5Typ e:C olla ge n#of RO Is:9Ma

37、 xP -9.9 15#of RO Is:1 7Ma xP -1 6.09 5#of RO Is:3 8F at Ma xP 30.03#of RO Is:4 4Int -28.65#of RO Is:8 2MB F -5 5.6 95#of RO Is:1 13MinP -1 7.9 15Typ e:C olla ge n#of RO Is:5MB F -5 3.1 5Typ e:C alciu m#of RO Is:2 0MinP -1 7.9 15#of RO Is:2 8MB F -5 5.6 95#of RO Is:3 31 46#of RO Is:TREEROOTIVUS 培训 T

38、he CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkComparison Between VH and Histology020406080100PredictiveAccuracySensitivitySpecificityFibrousFibro-fattyDense calciumNecrotic coreIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New YorkVirtual HistologyTMIVUS 培训 The CardiovascularResearch FoundationLenox Hill Heart and VascularInstitute of New York谢谢！谢谢！IVUS 培训