血管內(nèi)超聲基礎(chǔ)知識(shí)

血管內(nèi)超聲基礎(chǔ)知識(shí)一、血管內(nèi)超聲基礎(chǔ)二、血管內(nèi)超聲和冠脈造影的關(guān)系三、主要適應(yīng)癥四、什么是VH南方會(huì)2008第1頁/共49頁第一頁，共50頁。RotatingElementDriveShaftMulti-elementArrayTherearetwotypesofimagingsystems:Mechanical(rotatingtransducer)andElectronicArray南方會(huì)2008第2頁/共49頁第二頁，共50頁。HighfrequencysoundwavesechooffvesselwallsandaresentbacktosystemSystemelectronicsprocessthesignal南方會(huì)2008第3頁/共49頁第三頁，共50頁。Intimaldisease(plaque)isdenseandwillappear‘white’Mediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound(appearsdark)Adventitiahas‘sheets’ofcollagenthatreflectalotofultrasound(appearswhite)南方會(huì)2008第4頁/共49頁第四頁，共50頁。南方會(huì)2008第5頁/共49頁第五頁，共50頁。CalciumBrightechoes(brighterthantheadventitia)Obstructsthepenetrationofultrasound(acousticshadowing)onlytheleadingedgeisdetectedandthicknesscannotbedetermined.Resultsinreverberations-theoscillationofultrasoundbetweentransducerandcalciumcausingrepeating‘a(chǎn)rcs’南方會(huì)2008第6頁/共49頁第六頁，共50頁。80°SuperficialDeepDeepCalciumisquantifiedbymeasuringthe“arc”itencompassesCalciumisclassifiedbyitslocationwithintheplaqueSuperficialcalciumisclosertothelumenthantotheadventitiaDeepcalciumisclosertotheadventitiathantothelumen南方會(huì)2008第7頁/共49頁第七頁，共50頁。FibroticPlaqueAsbrightorbrighterthantheadventitia(hyperechoic)MajorityofatheroscleroticlesionsarefibroticVerydense,fibrousplaquesmaycausesomuchacousticshadowingthattheycouldbemisclassifiedascalcified南方會(huì)2008第8頁/共49頁第八頁，共50頁。SoftPlaqueNotasbrightastheadventitia(hypoechoic)“Soft”referstothelowechogenicity,generallyduetohighlipidcontentinamostlycellularlesion.Reducedechodensitymayalsobedueto:necroticzonewithinplaqueintramuralhemorrhagethrombus南方會(huì)2008第9頁/共49頁第九頁，共50頁。VulnerablePlaqueFibrousCapLipidCore南方會(huì)2008第10頁/共49頁第十頁，共50頁。MixedPlaque南方會(huì)2008第11頁/共49頁第十一頁，共50頁。014mmExampleofThrombus南方會(huì)2008第12頁/共49頁第十二頁，共50頁。BasicMeasurements(I)Externalelasticmembrane(EEM)crosssectionalarea(CSA)=totalarterialCSA=‘media’areatracingtheboundarybetweenthedarkmediaandthe

brightadventitia(i.e.,theapparentouteredgeofthemediastripe)LumenCSAMaxandminlumendiametersStentCSAMaxandminstentdiametersPlaque+media(P+M)CSA=EEM-LumenCSAinnon-stentedlesions=EEM-stentCSAinstentedlesionsIntimalhyperplasiaCSA=Stent-LumenCSA南方會(huì)2008第13頁/共49頁第十三頁，共50頁。BasicMeasurements(II)Eccentricity=maximum/minimumP+MthicknessPlaqueBurden(=cross-sectionalnarrowingor%plaquearea)=P+M/EEMCSARemodelingIndex=Lesion/ReferenceEEMCSAAreaStenosis=(Reference-Lesion)/ReferenceLumenCSAArcofcalciumLesionlengthsmeasuredusingmotorizedtransducerpullback,ideallyat0.5mm/sec南方會(huì)2008第14頁/共49頁第十四頁，共50頁。Non-stentedarteryEEMGuidewiresIVUScatheterPlaque+mediaLumen南方會(huì)2008第15頁/共49頁第十五頁，共50頁。StentedArteryEEMLumenStentGuidewireIVUScatheterPlaque+mediaIntimalhyperplasia南方會(huì)2008第16頁/共49頁第十六頁，共50頁。ProximalReferenceLesionSiteDistalReferenceEEMLumenP+MMaxP+MThicknessMinP+MThicknessCa++南方會(huì)2008第17頁/共49頁第十七頁，共50頁。03mm12mmProximalReferenceLesionSiteDistalReferenceEEMCSA=20.4LumenCSA=9.7Maxlumendiam=3.7MLD=3.1P+MCSA=10.7Eccentricity=1.0/0.3Plaqueburden=0.52ArcofCa=60EEMCSA=21.6LumenCSA=4.5Maxlumendiam=32.8MLD=2.3P+MCSA=17.1Eccentricity=3.0/0.1Plaqueburden=0.79EEMCSA=13.3LumenCSA=8.9Maxlumendiam=3.6MLD=3.0P+MCSA=4.4Eccentricity=0.6/0.2Plaqueburden=0.33AverageReferenceEEMCSA=16.9RemodelingIndex=1.3AverageReferenceLumenCSA=9.3AreaStenosis=52%南方會(huì)2008第18頁/共49頁第十八頁，共50頁。In-StentRestenosisIn-stentintimalhyperplasia(IH)oftenappearswithaverylowechogenicityCouldbelessechogenicthanthebloodspeckleAppropriatesystemsettingsarecriticaltovisualizeIH(donot“blackout”center)南方會(huì)2008第19頁/共49頁第十九頁，共50頁。血管內(nèi)超聲基礎(chǔ)知識(shí)一、血管內(nèi)超聲基礎(chǔ)二、血管內(nèi)超聲和冠脈造影的關(guān)系三、主要適應(yīng)癥四、什么是VH南方會(huì)2008第20頁/共49頁第二十頁，共50頁。LimitationsofCoronaryAngiographyFocalDisease50%Lesion50%LesionDiffuseDiseaseAngiogramSilhouette南方會(huì)2008第21頁/共49頁第二十一頁，共50頁。AngiographicallySilentDiseaseIn884nativecoronaryarteries,theplaqueburdenintheangiographically“normal”referencesegmentwas51±13%MintzGS,etal.JAmCollCardiol1995;25:1479-1485南方會(huì)2008第22頁/共49頁第二十二頁，共50頁。CoronaryRemodelingHypothesisCompenatoryExpansion

MaintainsConsistantLumenExpansion

Overcome:LumenNarrowsNormalVesselMinimalCADModerateCADSevereCAD南方會(huì)2008第23頁/共49頁第二十三頁，共50頁。ProximalreferenceLesionDistalreferenceIntermediateremodelingNegativeremodelingPositiveremodelingNishioka.

JACC1996;27:1571-1576DicotomousClassificationofRemodeling南方會(huì)2008第24頁/共49頁第二十四頁，共50頁。IrregularPlaque/IrregularLumenACross-sectionRAOViewLAOViewBC南方會(huì)2008第25頁/共49頁第二十五頁，共50頁。IVUSEEMCSA=22.7mm2LumenCSA=16.6mm2Meanlumendiameter=4.6mmQCA9FguidingcatheterReferencediameter=3.12mm南方會(huì)2008第26頁/共49頁第二十六頁，共50頁。血管內(nèi)超聲基礎(chǔ)知識(shí)一、血管內(nèi)超聲基礎(chǔ)二、血管內(nèi)超聲和冠脈造影的關(guān)系三、主要適應(yīng)癥四、什么是VH南方會(huì)2008第27頁/共49頁第二十七頁，共50頁。ValidationofIVUSAssessmentofIschemiaProducingStenosis(DopplerFloWireandSPECT)IVUSMLA4.0mm2IVUSMLA<4.0mm2CFR<2.0227CFR2.0394Diagnosticaccuracy=92%.Abizaidetal,AJC1998;82:42-8IVUSMLA4.0mm2IVUSMLA<4.0mm2+Spect442-Spect201Diagnosticaccuracy=93%.Nishiokaetal,JACC1999;33:1870-8南方會(huì)2008第28頁/共49頁第二十八頁，共50頁。IVUSCriteriafora‘Significant’StenosisBasedonthestudiescomparingIVUStoflowwire,pressurewire,orSPECTthalliumandbasedonstudieswithclinicaloutcome-mostfeelthatalumenarealessthan4.0mm2inaproximalepicardialarteryexcludingtheLeftMainisaflowlimitingstenosis南方會(huì)2008第29頁/共49頁第二十九頁，共50頁。PoorinterobserveragreementintheangiographicassessmentofLMCAstenosisintheCASSstudyII(Cameronetal.Circulation1983;68:484-489)FivegradesofLMseverity1: 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: 4gradesofdifferenceClinicalsitevs

QualitycontrolClinicalsitevs

StudyGroupStudyGroupvsQualitycontrol南方會(huì)2008第30頁/共49頁第三十頁，共50頁。ReferenceLesion10mmLumenCSA=18.3mm2Lumendiameter=5.0mmLumenCSA=3.6mm2Lumendiameter=1.3mmLumenCSA=11.9mm2Lumendiameter=3.5mmPatientwithnormalostialLMCAwhopreviouslyunderwentCABGforpresumedLMCAdiseasePatientwithsevere,butunrecognized,distalLMCAstenosiswhowasreferredforPTCAofLAD南方會(huì)2008第31頁/共49頁第三十一頁，共50頁。SuggestedIVUSCriteriafora‘Significant’LMCAStenosisMostIVUSLMCAstudiesshoweitherinsignificantdiseaseorcriticaldisease,onlyaminorityrequirecarefulquantificationLumenCSA<6.0mm2orMLD<3.0mmaresuggestedcriteriaforasignificantLMCAstenosisThesumofthelumenareasofthetwodaughtervessels(LADandLCX,eachofwhichshouldbe4.0mm2)=150%oftheparent(LM)ThesecorrelatedwithanabnormalFFR

(JastietalCirculation2004;110:2831-6)南方會(huì)2008第32頁/共49頁第三十二頁，共50頁。UnusualLesions:IVUSClassificationofAngiographicAneurysmsOf77angiographicaneurysms21(27%)trueaneurysm3(4%)pseudoaneurysm12(16%)complexplaquesorunhealeddissections41(53%)normalsegmentadjacenttooneormorestenosesTrue

AneurysmPSAComplex

PlaqueNormalSitewith

AdjacentStenosesNopriorPCI100626PriorPCI113615(Maeharaetal.AmJCardiol2001;88:365-70)南方會(huì)2008第33頁/共49頁第三十三頁，共50頁。ProximalDistalLesion5.5mm

MaxLD=3.5mm

MaxLD=3.3mm6mmStentsizingusingIVUS南方會(huì)2008第34頁/共49頁第三十四頁，共50頁。Thehighpredictivevalue(90%)fortheminimumstentCSAinCypherstentssuggeststhatmostcausesofCypherstentfailurewillbe“mechanical”

01020304050607080901003.54.06.57.07.58.08.5F/UMLA>4.0mm2(%)Cypher5.0**sensitivityspecificity01020304050607080901003.54.04.55.05.56.07.07.58.08.5F/UMLA>4.0mm2(%)BareMetalStents6.5*Minimumstentarea(mm2)Minimumstentarea(mm2)(Sonodaetal.JAmCollCardiol2004;43:1959-63)*predictivevalue=56%**predictivevalue=90%南方會(huì)2008第35頁/共49頁第三十五頁，共50頁。Predictorsofangiographicrestenosisin550ptswith670nativearterylesionstreatedwithCypherstents0204060801000204060801003.54.04.55.05.56.06.57.07.5Angiographicrestenosis(%)Angiographicrestenosis(%)IVUSMSA(mm2)10152025303540455560657075IVUStotalstentlength(mm)<5.5mm2≥5.5mm2≤40mm2.4%0.4%>40mm17.7%8.6%(Hongetal.unpublished)南方會(huì)2008第36頁/共49頁第三十六頁，共50頁。ComparisonofIVUS-measuredminimumstentdiameter(MSD)andminimumstentarea(MSA)withthepredictedmeasurementsfromCordis(Cypherinyellow,n=133)andBSC(Taxusinred,n=67).DESachieveanaverageofonly75%ofthepredictedMSD(66%ofMSA)IVUSMeasuredMSA(mm2)PredictedMSA(mm2)IVUSMeasuredMSD(mm)PredictedMSD(mm)24%南方會(huì)2008第37頁/共49頁第三十七頁，共50頁。Peri-StentHaziness:DoubleLumen南方會(huì)2008第38頁/共49頁第三十八頁，共50頁。Peri-StentHaziness:PlaqueBurdenTwoOverlappingStentsHazySegment南方會(huì)2008第39頁/共49頁第三十九頁，共50頁。Peri-StentHaziness:CalcificationStent南方會(huì)2008第40頁/共49頁第四十頁，共50頁。Peri-StentInjury:PlaqueTearUltrasoundSiteStent南方會(huì)2008第41頁/共