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1、冠心病介入诊疗-ABC,1929年,德国医生Wenner Forssmann在自己身上进行了人类首例心导管检查术. 他将导管经左肘前静脉,锁骨下静脉,上腔静脉送入右心房,并拍了医学史上第一张右心导管胸片,从此揭开了介入心脏病学的序幕.,1959年Mason Sones 利用特制的尖端呈弧形的造影导管,经肱动脉送入主动脉根部进行主动脉造影,无意中将造影剂直接注入右冠状动脉内使其清晰显影, 这一偶然事件开创了冠脉介入诊断技术的新纪元,冠脉造影50余年的历程!,CA introduced by F. Mason Sones, Jr, MD (首次冠脉造影) The first human studi
2、es- severity and extent of CAD (首个人体研究) Earliest natural history studies of proven CAD Dynamic visualization of LV performance (左室造影) Demonstration of prompt and complete revascularization by CABG Refinement of natural history studies of unoperated CAD patients Discovery of the benefit of CABG vs. M
3、ed Rx in subsets of patients Delineation of coronary vasospasm and Prinzmetals angina(冠脉痉挛) Significance of coronary pathoanatomy (ulceration, thrombus, dissection, aneurysm, muscle bridge, collateral vessels) Introduction of PTCA and delineation of restenosis (PTCA及再狭窄) First angiographic evidence
4、of clot lysis in a coronary vessel,1950s,1960s,1970s,Ryan Circulation 2002, 106:752-756,冠脉造影50余年的历程!,Thrombolytic era, with the demonstration of spontaneous fibrinolysis during 24 hrs of acute occlusions (心梗24小时内的血栓自溶) Plaque regression studies uncovering the clinical benefits of statin therapy (他汀治
5、疗斑块消褪) Delineation of the pathogenesis of AMI from studies outlining angiographic progression to MI (AMI的发病机制) Estimates of coronary flow using TFG and TFC Comparisons of PCI vs CABG for revascularization outcomes Stents era Myocardial blush (心肌染色分级) Brachytherapy, late stent thrombosis, and pharmoc
6、otherapy The coronary catheter and newer imaging devices (intravascular ultrasound, MRI),1980s,1990s,Ryan Circulation 2002, 106:752-756,2013,冠脉造影 股动脉及桡动脉路径,股神经,股总动脉,股静脉,穿刺位置,股骨头,腹股沟韧带,尺动脉,桡动脉,肱动脉,解剖学,桡动脉,掌浅弓,尺动脉,Allen 试验,Allen 试验解读,Assement of ulnar arch by oxymetry,Allens test is subjective and dif
7、ficult to interpret Barbeau score,Barbeau. G et al; Am Heart J 2004;147:48993,2 min,Barbeau. G et al; Am Heart J 2004;147:48993,NO,Barbeau score,冠脉造影 导管,Judkins,Amplatz,Tiger 导管,JR4 导管,冠脉解剖学,左主干(LM) 左前降支(LAD) 对角支(D1, D2) 间隔支(septal),LAD,D1,Septal,D2,LMS,RCA,PLV,INF,PDA,AM,左前降支,Radiographics 2007;27:
8、1569-1582,Radiographics 2007;27:1569-1582,右冠状动脉,Marginal branch,Conus branch,Marginal branch,回旋支,回旋支 (Cx) 钝缘支 (OM1, OM2),OM1,CX,OM2,LAD,Radiographics 2007;27:1569-1582,回旋支,OM,OM,LMS,CX,CX,OM,Radiographics 2007;27:1569-1582,中间支,IM,CX,LMS,右优势: This occurs when the descending, inferior, and posterior b
9、ranches all arise from the RCA. 均衡型: This occurs when only the descending branch arises from the RCA, while the inferior and posterior branches arise from the CX. 左优势: This occurs when all three branches arise from the CX.,冠脉优势型,后侧支(PL),后降支(PD),冠脉起源异常,左主干起源于右冠窦,http:/www.radiologyassistant.nl/en/482
10、75120e2ed5,心肌桥,Myocardial bridge in LAD,http:/www.radiologyassistant.nl/en/48275120e2ed5,A myocardial bridge occurs when one of the coronary arteries tunnels through the myocardium rather than resting on top of the myocardium,冠脉造影提供的信息,定量冠脉造影分析 冠脉血流 心肌灌注 其他特性: 钙化 血栓 溃疡 夹层 动脉瘤,钙化,定量冠脉造影分析(QCA),1近端参考血
11、管直径: 2. 最小直径: 3. 远端参考血管直径: 4. 病变长度: 直径狭窄:,1,2,3,4,病变特征描述,偏心: The plaque is twice as large on one side of the arterial border compared with the other. 钙化: Readily apparent densities noted within the apparent vascular wall at the site of the stenosis. 弥漫: Lesion is 20 mm in length. 分叉: Atherosclerotic
12、 plaque involves the origin of two separate arteries. 开口: Lesion beginning within 3-5 mm of the origin of a major epicardial artery.,Bifurcation,Ostial,TIMI 血流分级,TIMI Flow grade: Classification of TFG Grade 0, no perfusion Grade 1, penetration without perfusion Grade 2, partial perfusion Grade 3, co
13、mplete perfusion,TFG0,TFG1,TFG2,TFG3,TIMI 计帧,TIMI Frame Count:,Gibson C M et al. Circulation 1999;99:1945-1950,Gibson et al found a mean corrected TFC (cTFC) for normal coronary arteries of 21 3.1 frames, yielding a 95% confidence interval for normal flow of (15, 27) frames.,The Frame Count Reserve
14、(FCR) can be calculated by dividing basal by hyperaemic TFC.,The Frame Count Velocity (FCV) can be calculated by multiplying the length of the coronary artery by the acquisition rate (12.5, 25, 30 f/s) and dividing by the TFC.,TIMI 心肌灌注分级,TIMI Myocardial Perfusion Grade: TMPG 0: Failure of dye to en
15、ter the microvasculature. TMPG 1: Dye slowly enters but fails to exit the microvasculature. TMPG 2: Delayed entry and exit of dye from the microvasculature. TMPG 3: Normal entry and exit of dye from the microvasculature.,Gibson et al. Circulation 2000; 101:125-130,直接PCI后，虽然心外膜冠状动脉血流率高，但再灌注未成功,Brener
16、 SJ et al. Circ CV Interv. 2012;5:563-9 Farkouh ME et al. Circ CV Interv. 2013;6:216-23,心肌灌注分级,TIMI血流,ST段回落,镜下远端栓子和无复流,TIMI 3 级血流 无微血管灌注,Henriques JPS et al. EHJ 2002;23:1112-7,血栓分级,Grade 0: No cine-angiographic characteristics of thrombus present. Grade 1: Hazy, possible thrombus present. Angiograp
17、hy demonstrates characteristics such as reduced contrast density, haziness, irregular lesion contour, or a smooth convex “meniscus“ at the site of total occlusion suggestive but not diagnostic of thrombus. Grade 2: Thrombus present small size: Definite thrombus with greatest dimensions less than or
18、equal to 1/2 vessel diameter. Grade 3: Thrombus present moderate size: Definite thrombus but with greatest linear dimension greater than 1/2 but less than 2 vessel diameters. Grade 4: Thrombus present large size: As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameter
19、s. Grade 5: Recent total occlusion, can involve some collateralization but usually does not involve extensive collateralization, tends to have a “beak” shape and a hazy edge or appearance of distinct thrombus. Grade 6: Chronic total occlusion, usually involving extensive collateralization, tends to
20、have distinct, blunt cutoff/edge and will generally clot up to the nearest proximal side branch.,Gibson CM et al. Circulation. 2001;103:2550-2554,Grade 5 thrombus,Grade 4 thrombus,动脉瘤,A localized arterial widening (dilatation) that usually manifests itself as a bulge. Its presence may lead to weaken
21、ing of the wall and eventual rupture. Grade 0: None no ectasia present. Grade 1: Ectasia visual assessment of ectasia 1 & 1.5 times the normal artery diameter located anywhere in the culprit artery.,病变复杂程度,AHA Task Force Definition as modified by Ellis et al: Type A: 3 months old and/or bridging col
22、laterals, inability to protect major side branches, or degenerated vein graft with friable lesions.,分叉病变: Medina分型,1,1,1,夹层分级,An intraluminal filling defect or flap associated with a hazy, ground-glass appearance. This category is sub-classified using the NHLBI system for grading dissection types: T
23、ype A: Radiolucent areas within the coronary lumen during contrast injection, with minimal or no persistence of contrast after dye has cleared. Type B: Parallel tracts or double lumen separated by a radiolucent area during contrast injection, with minimal or no persistence after dye has cleared. Typ
24、e C: Contrast outside the coronary lumen, with persistence of contrast in the area after dye has cleared. Type D: Spiral luminal filling defects frequently with extensive contrast staining of the vessel. Type E: New persistent filling defects that may be caused by thrombus. Type F: These are non A E
25、 dissection types that lead to impaired flow or total occlusion of the coronary artery.,Dissection-Type D,Dissection flap post POBA in a heavily calcified lesion- Type C,其他,穿孔: Presence of extra-luminal contrast that develops during the procedure. 分支丢失: The development of TIMI grade 0 or 1 flow in a
26、 side branch that was 1.5 mm in diameter prior to the procedure and was initially patent with TIMI grade 2 or 3 flow. 手术成果: Complete success: If the post-procedure visual residual stenosis is 50% residual stenosis by visual assessment or if TIMI Grade 2 Flow is attained (this includes TFG 2.5). Fail
27、ure: If there is a persistent total occlusion, if the lesion cannot be crossed, or if there is persistent abrupt closure.,Perforation,Perforation,Pre,Post,其他,远端栓塞: The appearance of an abrupt cutoff in the distal vessel following PTCA. 无复流: Markedly delayed flow down the artery with minimal residual
28、 stenosis.,侧枝循环,Partial: Minimal collaterals present. Evidence of minimal to partial filling of the recipient branch epicardial arteries/infarct region. Complete: Well-developed collaterals. Evidence of collateral circulation with near complete to complete filling of the recipient major epicardial a
29、rtery/infarct region.,LAD,RCA,支架内再狭窄,IVUS interrogation has identified IH as the main cause of ISR,Eur Heart J (2003) 24 (2): 138-150.,支架内血栓,IVUS provides an attractive technique to characterise fully the pattern of stent thrombosis, to identify readily the underlying mechanical predisposing factors
30、, and to guide repeated coronary interventions,Heart. 2004 December; 90(12): 14551459,A,E,D,C,B,F,Case example of a 59 year old woman who presented with CS in the setting of STEMI (late presentation with ongoing symptoms). Initial angio showed thrombus LMS, CX (Panel A- arrow). Export aspiration cle
31、ared the thrombus (Panel B) with evidence of haziness in the ostial LMS (Panel C) confirmed on IVUS as a plaque in ostial LMS (Panel D) which was treated successfully with LMS stenting (Panel E), with widely patent stent at 3-month follow-up angio (Panel F).,斑块破裂,血栓形成/急性ST段抬高心梗,Cardiogenic shock in women. Kunadian et al. ICCL 2012,Ruptured plaque visible on angio,