造影结果的判读及病变类型的分析黄文晖

造影结果的判读及病变类型的分析 黄文晖 广东省人民医院 广东省心血管病研究所 从造影片我们要看什么？ 如何体位的片中判断正常的冠脉血管？ 如何判断病变的血管？ 常用的一些分类 通过不同的病变类型如何考虑介入治疗 的难度？ 从造影片我们要看什么？ 血管的情况 肺野的情况 心包情况 现场还要注意压力 的变化 正常冠状动脉 RCA Basic Anatomy Origin right aortic sinus(lower origin than LCA) Course Down right AV groove toward crux of the heart, gives off PDA(85%) from which septals arise, continues in LAV groove giving off posterior LV branches(posterolaterals). PDA may originate more proximally, bifurcate early or be small with part of “its territory” supplied by an acute marginal branch. RCA Other Branches Conus Artery(圆锥支 ) usually very proximal; courses anteriorly and upward over the RV outflow tract toward the LAD. May be an important Source of collaterals. SA Nodal Artery(窦房结动脉 ) (60%) usually 2nd branch of RCA-courses obliquely backward through uper portion of aterial septum and anteromedial wall of the RA-supplies SA node,usually RA and sometimes LA RCA Other Branches PDA(后降支 ) Supplies inferior wall, ventricular septum, posteromedial papillary muscle. AV Nodal Artery (房室结支 ) Arises at or near crux; supplies AV node. Right ventricular(Acute marginal Branches锐 缘支 ) Arise from mid RCA; Supply anterior RV; may be a collateral source. RCA Optimal View(s) LAO(30) Cranial(30) particularly for distal bifurcation(AP cranial may be better). RAO main shaft; cranial enhances distal vessels and very proximal; caudal may help with shepherds crook. Lateral bifurcations with RV branches-distal bifurcation, particularly with cranial. RCA 圆锥支 窦房结支 右室支 锐缘支 后降支 后侧支 LCA LM Optimal Views LAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUS LAD Course down the anterior interventricular groove- usually reaches apex. In 22% of cases does not reach apex LCA Branches septals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus( courses like 1st diagonal). LAD supplies anterolateral, apex and septum; 45%-55% of left ventricle. LCX Branches obtuse marginal, posterolaterals-supply posterolateral LV, anterolteral papillary muscles. SA node artery 38% Supplies 15%-25% of LV, unless dominant(supplies 40-50% of LV). AP Caudal view of LCA AP Cranial LAO Cranial View LAO Caudal View AHA/ACC冠脉病变分类 A型病变 散在病变 (长度 2cm) 近端节段过度弯曲 节段间成角 900 管腔完全闭塞 3个月 不能防止主要的分支受损 移植静脉退行性变易碎破 TIMI 血流分级 0级 : 无灌注 ,梗塞相关血管完全闭塞 ,无造 影剂 通过狭窄部位 . 1级 : 少量造影剂通过病变 ,但不能使远端动脉血 管床充分显影 2级 :血流 3个心动周期才能使病变远端的动脉 血管床充分显影 (30桢 /秒 ) 3级 :完全灌注 , 3个心动周期远端的动脉血管床 充分显影 (30桢 /秒 ) TIMI心肌灌注分级 (TMPG) 0级 :心肌无明显组织灌注 ,罪犯血管区域 无毛玻璃样改变或心肌显影 ,提示组织水 平灌注低下。 1级 ：造影剂缓慢灌注心肌，但不能从微血管 排空，毛玻璃样改变或罪犯血管区域心肌显影 不能从微血管清除，心肌显影在开始下一个造 影序列（间隔 30秒）时仍然存在。 TIMI心肌灌注分级