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1、血管内超声基础知识 阜外医院 钱杰,南方会2008,血管内超声基础知识,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,南方会2008,Rotating Element,Drive Shaft,Multi-element Array,There are two types of imaging systems: Mechanical (rotating transducer) and Electronic Array,南方会2008,High frequency sound waves echo off vessel walls and are sent b
2、ack to system,System electronics process the signal,南方会2008,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),南方会20
3、08,南方会2008,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 repeatin
4、g arcs,南方会2008,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,南方会2008,Fibrotic Plaque,As bright or brighte
5、r 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,南方会2008,Soft Plaque,Not as bright as the adventitia (hypoechoic) “Soft” refers to the low echogenicity,
6、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,南方会2008,Vulnerable Plaque,Fibrous Cap,Lipid Core,南方会2008,Mixed Plaque,南方会2008,0,1,4mm,Example of Thrombus,南方会2008,Basic Measurements (I)
7、,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+m
8、edia (P+M) CSA = EEM - Lumen CSA in non-stented lesions = EEM - stent CSA in stented lesions Intimal hyperplasia CSA = Stent - Lumen CSA,南方会2008,Basic Measurements (II),Eccentricity = maximum/minimum P+M thickness Plaque Burden (=cross-sectional narrowing or %plaque area) = P+M/EEM CSA Remodeling In
9、dex = 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,南方会2008,Non-stented artery,南方会2008,Stented Artery,南方会2008,Proximal Reference,Lesion Site,Distal Reference,EEM,Lume
10、n,P+M,Max P+M Thickness,Min P+M Thickness,Ca+,南方会2008,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
11、 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%,南方会2008,In
12、-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),南方会2008,血管内超声基础知识,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,南方会2008,Limit
13、ations of Coronary Angiography,Focal Disease,50% Lesion,50% Lesion,Diffuse Disease,Angiogram Silhouette,南方会2008,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;25:1
14、479-1485,南方会2008,Coronary Remodeling Hypothesis,Compenatory Expansion Maintains Consistant Lumen,Expansion Overcome: Lumen Narrows,Normal Vessel,Minimal CAD,Moderate CAD,Severe CAD,南方会2008,Proximal reference,Lesion,Distal reference,Intermediate,remodeling,Negative,remodeling,Positive,remodeling,Nish
15、ioka. JACC 1996; 27:1571-1576,Dicotomous Classification of Remodeling,南方会2008,Irregular Plaque / Irregular Lumen,A,Cross-section,RAO View,LAO View,B,C,南方会2008,IVUS EEM CSA = 22.7mm2 Lumen CSA = 16.6mm2 Mean lumen diameter = 4.6mm,QCA 9F guiding catheter Reference diameter = 3.12mm,南方会2008,血管内超声基础知识,
16、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,南方会2008,Validation of IVUS Assessment of Ischemia Producing Stenosis (Doppler FloWire and SPECT),Diagnostic accuracy = 92%. Abizaid et al, AJC 1998;82:42-8,Diagnostic accuracy = 93%. Nishioka et al, JACC 1999;33:1870-8,南方会2008,IVUS Criteria for a Significant
17、 Stenosis,Based on the studies comparing IVUS to flow wire, pressure wire, or SPECT thallium and based on studies with clinical outcome - most feel that a lumen area less than 4.0 mm2 in a proximal epicardial artery excluding the Left Main is a flow limiting stenosis,南方会2008,Poor interobserver agree
18、ment 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
19、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,南方会2008,Reference,Lesion,10 mm,Lumen CSA = 18.3mm2 Lumen diameter = 5.0mm,Lumen CSA = 3.6mm2 Lume
20、n diameter = 1.3mm,Lumen CSA = 11.9mm2 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,南方会2008,Suggested IVUS Criteria for a Significant LMCA St
21、enosis,Most IVUS LMCA studies show either insignificant disease or critical disease, only a minority require careful quantification Lumen CSA 6.0mm2 or MLD 3.0mm are suggested criteria for a significant LMCA stenosis The sum of the lumen areas of the two daughter vessels (LAD and LCX, each of which
22、should be 4.0mm2) = 150% of the parent (LM) These correlated with an abnormal FFR (Jasti et al Circulation 2004;110:2831-6),南方会2008,Unusual Lesions: IVUS Classification of Angiographic Aneurysms,Of 77 angiographic aneurysms 21 (27%) true aneurysm 3 (4%) pseudoaneurysm 12 (16%) complex plaques or unh
23、ealed dissections 41 (53%) normal segment adjacent to one or more stenoses,(Maehara et al. Am J Cardiol 2001;88:365-70),南方会2008,Proximal,Distal,Lesion,Max LD = 3.5 mm,Max LD = 3.3 mm,Stent sizing using IVUS,南方会2008,The high predictive value (90%) for the minimum stent CSA in Cypher stents suggests t
24、hat most causes of Cypher stent failure will be “mechanical”,南方会2008,Predictors of angiographic restenosis in 550 pts with 670 native artery lesions treated with Cypher stents,Angiographic restenosis (%),Angiographic restenosis (%),IVUS MSA (mm2),IVUS total stent length (mm),(Hong et al. unpublished
25、),南方会2008,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),南方会2008,Peri-Stent Haziness: Double
26、 Lumen,南方会2008,Peri-Stent Haziness: Plaque Burden,南方会2008,Peri-Stent Haziness: Calcification,Stent,南方会2008,Peri-Stent Injury: Plaque Tear,南方会2008,何时采用IVUS 以达到最佳的 DES 置入,所有支架置入失败病例 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
27、 (特别是具有上述矛盾的结果和危险因素),南方会2008,血管内超声基础知识,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,南方会2008,Virtual HistologyTM Volcano,南方会2008,Virtual HistologyTM Volcano,南方会2008,Comparison Between VH and Histology,Diagnostic accuracy,南方会2008,FIBROTIC FIBRO-LIPIDIC LIPIDIC-CORE CALCIFIC,Virtual HistologyTM,Ex-Vivo Validation,南方会2008,谢谢！,南方会2008,