IVUS血管内超声基础和临床.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,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,Rotating Element,Drive Shaft,Multi-element Array,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,There are two types of imaging systems:Mechanical(rotating transducer)and Electronic Array,IVUS,培训,High frequency sound waves echo off vessel walls and are sent back to system,System electronics process the signal,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,A,L,A=Axial Resolution,L=Lateral Resolution,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,Low dynamic range,High dynamic range,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,Intimal disease(plaque)is dense and will appear white,Media 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 CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,Calcium,Bright echoes(brighter than the adventitia),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 arcs,IVUS,培训,80,Superficial,Deep,Deep,Calcium is,quantified,by measuring the“arc”it encompasses,Calcium is,classified,by its location within the plaque,Superficial calcium is closer to the lumen than to the adventitia,Deep calcium is closer to the adventitia than to the lumen,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,Fibrotic Plaque,As bright or brighter than the adventitia(hyperechoic),Majority of atherosclerotic lesions are fibrotic,Very dense,fibrous plaques may cause so much acoustic shadowing that they could be misclassified as calcified,IVUS,培训,Soft Plaque,Not as bright as the adventitia(hypoechoic),“Soft”refers to the low echogenicity,generally due to high lipid content in a mostly cellular lesion.,Reduced echodensity may also be due to:,necrotic zone within plaque,intramural hemorrhage,thrombus,IVUS,培训,Vulnerable Plaque,Fibrous Cap,Lipid Core,IVUS,培训,Mixed Plaque,IVUS,培训,0,1,4,mm,Example of Thrombus,IVUS,培训,Examples of Thrombus,IVUS,培训,Basic Measurements(I),External elastic membrane(EEM)cross sectional area(CSA)=total arterial CSA =media area,tracing the boundary between the dark media and the,bright adventitia(i.e.,the apparent outer edge of the media stripe),Lumen CSA,Max and min lumen diameters,Stent CSA,Max and min stent diameters,Plaque+media(P+M)CSA,=EEM-Lumen CSA in non-stented lesions,=EEM-stent CSA in stented lesions,Intimal hyperplasia CSA=Stent-Lumen CSA,IVUS,培训,Basic Measurements(II),Eccentricity=maximum/minimum P+M thickness,Plaque Burden(=cross-sectional narrowing or%plaque area),=P+M/EEM CSA,Remodeling Index=Lesion/Reference EEM CSA,Area Stenosis,=(Reference-Lesion)/Reference Lumen CSA,Arc of calcium,Lesion lengths measured using motorized transducer pullback,ideally at 0.5 mm/sec,IVUS,培训,Non-stented artery,EEM,Guidewires,IVUS catheter,Plaque+media,Lumen,IVUS,培训,Stented Artery,EEM,Lumen,Stent,Guidewire,IVUS catheter,Plaque+media,Intimal hyperplasia,IVUS,培训,Proximal Reference,Lesion,Site,Distal Reference,EEM,Lumen,P+M,Max P+M Thickness,Min P+M Thickness,Ca,+,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,0,3,mm,12,mm,Proximal Reference,Lesion,Site,Distal Reference,EEM CSA=20.4,Lumen CSA=9.7,Max lumen diam=3.7,MLD=3.1,P+M CSA=10.7,Eccentricity=1.0/0.3,Plaque burden=0.52,Arc of Ca=60,EEM CSA=21.6,Lumen CSA=4.5,Max lumen diam=32.8,MLD=2.3,P+M CSA=17.1,Eccentricity=3.0/0.1,Plaque burden=0.79,EEM CSA=13.3,Lumen CSA=8.9,Max lumen diam=3.6,MLD=3.0,P+M CSA=4.4,Eccentricity=0.6/0.2,Plaque burden=0.33,Average Reference EEM CSA=16.9,Remodeling Index=1.3,Average Reference Lumen CSA=9.3,Area Stenosis=52%,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,培训,In-Stent Restenosis,In-stent intimal hyperplasia(IH)often appears with a very low echogenicity,Could be less echogenic than the blood speckle,Appropriate system settings are critical to visualize IH(do not“black out”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,Limitations of Coronary Angiography,Focal Disease,50%,Lesion,50%,Lesion,Diffuse Disease,Angiogram Silhouette,IVUS,培训,Angiographically Silent Disease,In 884 native coronary arteries,the plaque burden in the angiographically“normal”reference segment was 5113%,Mintz GS,et al.J Am Coll Cardiol 1995;25:1479-1485,IVUS,培训,Coronary Remodeling Hypothesis,Compenatory ExpansionMaintains Consistant Lumen,ExpansionOvercome:Lumen Narrows,Normal Vessel,Minimal CAD,Moderate CAD,Severe CAD,IVUS,培训,Proximal reference,Lesion,Distal reference,Intermediate,remodeling,Negative,remodeling,Positive,remodeling,Nishioka.,JACC 1996;27:1571-1576,Dicotomous Classification of Remodeling,IVUS,培训,A,B,D,E,f,f,C,F,distal,Lumen,e,b,e,b,Lumen,Positive Remodeling,Negative Remodeling,c,c,distal,EEM,EEM,IVUS,培训,Limitations of Coronary Angiography,Angiogram Silhouette,Coronary Cross-section,75%,25%,IVUS,培训,Irregular Plaque/Irregular Lumen,A,Cross-section,RAO View,LAO View,B,C,IVUS,培训,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,IVUS,EEM CSA=22.7mm,2,Lumen CSA=16.6mm,2,Mean lumen diameter=4.6mm,QCA,9F guiding catheter,Reference diameter=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,(,Fisher et al.CCD 1982;8:565-575),Comparison between percent stenosis assessment from the quality control lab vs the clinical site,*,area of the square is proportional to the number of cases with the given reading,QC lab,Clinical site,100,0,100,0,Of 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-I,Poor interobserver agreement in the angiographic assessment of LMCA stenosis in the CASS study-II,(,Cameron et al.Circulation 1983;68:484-489),Five grades of LM severity,1:0-24%,DS,2:25-49%DS,3:50-74%DS,4:75-89%DS,5:90-100%DS,#,of grades of difference in assessment of LM 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 difference,Clinical site vs Quality control,Clinical site vs Study Group,Study Group vs Quality control,IVUS,培训,IVUS,培训,Reference,Lesion,10 mm,Lumen CSA=18.3mm,2,Lumen diameter=5.0mm,Lumen CSA=3.6mm,2,Lumen diameter=1.3mm,Lumen CSA=11.9mm,2,Lumen diameter=3.5mm,Patient with normal ostial LMCA who previously underwent CABG for presumed LMCA disease,Patient with severe,but unrecognized,distal LMCA stenosis who was referred for PTCA of LAD,Suggested IVUS Criteria for a Significant,LMCA,Stenosis,Most IVUS LMCA studies show either insignificant disease or critical disease,only a minority require careful quantification,Lumen CSA 6.0mm,2,or MLD 4.0mm,2,(%),Cypher,5.0*,sensitivity,specificity,0,10,20,30,40,50,60,70,80,90,100,3.5,4.0,4.5,5.0,5.5,6.0,7.0,7.5,8.0,8.5,F/U MLA 4.0mm,2,(%),Bare Metal Stents,6.5*,Minimum stent area(mm,2,),Minimum stent area(mm,2,),(,Sonoda et al.J Am Coll Cardiol 2004;43:1959-63),*,predictive value=56%,*,predictive value=90%,Predictors of angiographic restenosis in 550 pts with 670 native artery lesions treated with Cypher stents,0,20,40,60,80,100,0,20,40,60,80,100,3.5,4.0,4.5,5.0,5.5,6.0,6.5,7.0,7.5,Angiographic restenosis(%),Angiographic restenosis(%),IVUS MSA(mm,2,),10,15,20,25,30,35,40,45,55,60,65,70,75,IVUS total stent length(mm),40,mm,17.7%,8.6%,(,Hong et al.unpublished),Comparison of IVUS-measured minimum stent diameter(MSD)and minimum stent area(MSA)with the predicted measurements from Cordis(Cypher in yellow,n=133)and BSC(Taxus in red,n=67).DES achieve an average of only 75%of the predicted MSD(66%of MSA),IVUS Measured MSA(mm,2,),Predicted MSA(mm,2,),IVUS Measured MSD(mm),Predicted MSD(mm),24%,Peri-Stent Haziness:Double Lumen,Peri-Stent Haziness:Plaque Burden,Two,Overlapping,Stents,Hazy,Segment,Peri-Stent Haziness:Calcification,Stent,Peri-Stent Injury:Plaque Tear,Ultrasound,Site,Stent,何时采用,IVUS,以达到最佳的,DES,置入,高危患者亚组,肾功能不全,SAT,双重抗血小板药物使用的局限性,SAT,糖尿病,ISR,SAT,左心室功能差,SAT,高危病变亚组,分叉病变,ISR,SAT,开口病变,ISR,小血管,ISR,长病变,ISR,治疗支架内再狭窄（,ISR,）,ISR,左主干病变,(,特别是具有上述矛盾的结果和危险因素,),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,PC with 500 MHz,and reconstruction software,Eliminate the S-VHS VCR,Virtual Histology,TM,Volcano,IVUS,培训,Virtual Histology,TM,Volcano,FIBROTIC,FIBRO-LIPID,CALCIFIC,LIPID,CORE,MEDIA,Legend,Classification,IVUS,培训,Comparison Between VH and Histology,Diagnostic accuracy,Nair et al.Circulation 2002,IVUS,培训,FIBROTIC FIBRO-LIPIDIC LIPIDIC-CORE CALCIFIC,Virtual Histology,TM,Ex-Vivo Validation,IVUS,培训,谢谢！,IVUS,培训,