IVUS-血管内超声基础和临床.ppt

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1、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,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 b

2、ack to system,System electronics process the signal,IVUS 培训,A,L,A=Axial ResolutionL=Lateral Resolution,IVUS 培训,Low dynamic range,High dynamic range,IVUS 培训,Intimal disease(plaque)is dense and will appear whiteMedia is made of homogeneous smooth muscle cells and does not reflect ultrasound(appears da

3、rk)Adventitia has sheets of collagen that reflect a lot of ultrasound(appears white),IVUS 培训,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 reverbera

4、tions-the oscillation of ultrasound between transducer and calcium causing repeating arcs,IVUS 培训,Calcium is quantified by measuring the“arc”it encompassesCalcium is classified by its location within the plaqueSuperficial calcium is closer to the lumen than to the adventitiaDeep calcium is closer to

5、 the adventitia than to the lumen,IVUS 培训,Fibrotic Plaque,As bright or brighter than the adventitia(hyperechoic)Majority of atherosclerotic lesions are fibroticVery dense,fibrous plaques may cause so much acoustic shadowing that they could be misclassified as calcified,IVUS 培训,Soft Plaque,Not as bri

6、ght 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 plaqueintramural hemorrhagethrombus,IVUS 培训,Vulnerable Plaque,Fibrous Cap,Lipid Core,IVUS 培训,Mixed Plaque,

7、IVUS 培训,0,1,4mm,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 areatracing the boundary between the dark media and thebright adventitia(i.e.,the apparent outer edge of the media stripe)Lu

8、men CSAMax and min lumen 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 CSA,IVUS 培训,Basic Measurements(II),Eccentricity=maximum/minimum P+M thicknessPlaque Burden(=cross-secti

9、onal 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/sec,IVUS 培训,Non-stented artery,IVUS 培训,Stented Artery,IVUS 培训,Proximal Re

10、ference,LesionSite,Distal Reference,EEM,Lumen,P+M,Max P+M Thickness,Min P+M Thickness,Ca+,IVUS 培训,Proximal Reference,LesionSite,Distal Reference,EEM CSA=20.4Lumen CSA=9.7 Max lumen diam=3.7MLD=3.1P+M CSA=10.7Eccentricity=1.0/0.3Plaque burden=0.52Arc of Ca=60,EEM CSA=21.6Lumen CSA=4.5 Max lumen diam=

11、32.8MLD=2.3P+M CSA=17.1Eccentricity=3.0/0.1Plaque burden=0.79,EEM CSA=13.3Lumen CSA=8.9 Max lumen diam=3.6MLD=3.0P+M CSA=4.4Eccentricity=0.6/0.2Plaque burden=0.33,Average Reference EEM CSA=16.9Remodeling Index=1.3Average Reference Lumen CSA=9.3Area Stenosis=52%,IVUS 培训,In-Stent Restenosis,In-stent i

12、ntimal hyperplasia(IH)often appears with a very low echogenicityCould be less echogenic than the blood speckleAppropriate 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

13、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 Hypothe

14、sis,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 Classifi

15、cation 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 Vie

16、w,B,C,IVUS 培训,IVUSEEM CSA=22.7mm2Lumen CSA=16.6mm2Mean lumen diameter=4.6mm,QCA9F guiding catheterReference 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 cont

17、rol lab vs the clinical site,*area of the square is proportional to the number of cases with the given reading,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,

18、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%DS2:25-49%DS3:50-74%DS4:75-89%DS5:90-100%DS,#of grades of difference in assessment of LM severity,0:no difference+1 or-1:1 g

19、rade 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=18.3mm2Lumen diameter=5.0mm,Lumen CSA=3.6mm2Lumen di

20、ameter=1.3mm,Lumen CSA=11.9mm2Lumen 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

21、 studies show either insignificant disease or critical disease,only a minority require careful quantificationLumen CSA 6.0mm2 or MLD 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 t

22、he parent(LM)These correlated with an abnormal FFR(Jasti et al Circulation 2004;110:2831-6),IVUS 培训,IVUS 培训,Unusual Lesions:IVUS Classification of Angiographic Aneurysms,Of 77 angiographic aneurysms 21(27%)true aneurysm3(4%)pseudoaneurysm12(16%)complex plaques or unhealed dissections41(53%)normal se

23、gment adjacent to one or more stenoses,(Maehara et al.Am J Cardiol 2001;88:365-70),Normal Segment with Adjacent Stenoses,True Aneurysm,Pseudoaneurysm,Ruptured Plaque,Proximal,Distal,Lesion,Max LD=3.5 mm,Max LD=3.3 mm,Stent sizing using IVUS,Reference segment disease provides a cushion for oversizing

24、,The high predictive value(90%)for the minimum stent CSA in Cypher stents suggests that most causes of Cypher stent failure will be“mechanical”,Predictors of angiographic restenosis in 550 pts with 670 native artery lesions treated with Cypher stents,Angiographic restenosis(%),Angiographic restenosi

25、s(%),IVUS MSA(mm2),IVUS total stent length(mm),(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 M

26、SD(66%of MSA),Peri-Stent Haziness:Double Lumen,Peri-Stent Haziness:Plaque Burden,Peri-Stent Haziness:Calcification,Stent,Peri-Stent Injury:Plaque Tear,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,Virtual HistologyTM Volcano,IVUS 培训,Virtual HistologyTM Volcano,IVUS 培训,Comparison Between VH and Histology,Diagnostic accuracy,IVUS 培训,FIBROTIC FIBRO-LIPIDIC LIPIDIC-CORE CALCIFIC,Virtual HistologyTM,Ex-Vivo Validation,IVUS 培训,谢谢！,IVUS 培训,