IVUS-血管内超声基础和临床课件

血管内超声基础和临床应用进展IVUS培训血管内超声基础和临床应用进展IVUS培训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VHIVUS培训血管内超声基础和进展一、血管内超声基础IVUS培训RotatingElementDriveShaftMulti-elementArrayTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkTherearetwotypesofimagingsystems:Mechanical(rotatingtransducer)andElectronicArrayIVUS培训RotatingElementDriveShaftMulHighfrequencysoundwavesechooffvesselwallsandaresentbacktosystemSystemelectronicsprocessthesignalTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训HighfrequencysoundwavesechALA=AxialResolutionL=LateralResolutionTheCardiovascular

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InstituteofNewYorkIVUS培训ALA=AxialResolutionTheCardLowdynamicrangeHighdynamicrangeTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训LowdynamicrangeHighdynamicIntimaldisease(plaque)isdenseandwillappear‘white’Mediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound(appearsdark)Adventitiahas‘sheets’ofcollagenthatreflectalotofultrasound(appearswhite)TheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训Intimaldisease(plaque)isdeTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训TheCardiovascular

ResearchFoCalciumBrightechoes(brighterthantheadventitia)Obstructsthepenetrationofultrasound(acousticshadowing)onlytheleadingedgeisdetectedandthicknesscannotbedetermined.Resultsinreverberations-theoscillationofultrasoundbetweentransducerandcalciumcausingrepeating‘arcs’IVUS培训CalciumBrightechoes(brighter80°SuperficialDeepDeepCalciumisquantifiedbymeasuringthe“arc”itencompassesCalciumisclassifiedbyitslocationwithintheplaqueSuperficialcalciumisclosertothelumenthantotheadventitiaDeepcalciumisclosertotheadventitiathantothelumenTheCardiovascular

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InstituteofNewYorkIVUS培训80°SuperficialDeepDeepCalciumFibroticPlaqueAsbrightorbrighterthantheadventitia(hyperechoic)MajorityofatheroscleroticlesionsarefibroticVerydense,fibrousplaquesmaycausesomuchacousticshadowingthattheycouldbemisclassifiedascalcifiedIVUS培训FibroticPlaqueAsbrightorbrSoftPlaqueNotasbrightastheadventitia(hypoechoic)“Soft”referstothelowechogenicity,generallyduetohighlipidcontentinamostlycellularlesion.Reducedechodensitymayalsobedueto:necroticzonewithinplaqueintramuralhemorrhagethrombusIVUS培训SoftPlaqueNotasbrightasthVulnerablePlaqueFibrousCapLipidCoreIVUS培训VulnerablePlaqueFibrousCapLiMixedPlaqueIVUS培训MixedPlaqueIVUS培训014mmExampleofThrombusIVUS培训014mmExampleofThrombusIVUS培ExamplesofThrombusIVUS培训ExamplesofThrombusIVUS培训BasicMeasurements(I)Externalelasticmembrane(EEM)crosssectionalarea(CSA)=totalarterialCSA=‘media’areatracingtheboundarybetweenthedarkmediaandthe

brightadventitia(i.e.,theapparentouteredgeofthemediastripe)LumenCSAMaxandminlumendiametersStentCSAMaxandminstentdiametersPlaque+media(P+M)CSA=EEM-LumenCSAinnon-stentedlesions=EEM-stentCSAinstentedlesionsIntimalhyperplasiaCSA=Stent-LumenCSAIVUS培训BasicMeasurements(I)ExternalBasicMeasurements(II)Eccentricity=maximum/minimumP+MthicknessPlaqueBurden(=cross-sectionalnarrowingor%plaquearea)=P+M/EEMCSARemodelingIndex=Lesion/ReferenceEEMCSAAreaStenosis=(Reference-Lesion)/ReferenceLumenCSAArcofcalciumLesionlengthsmeasuredusingmotorizedtransducerpullback,ideallyat0.5mm/secIVUS培训BasicMeasurements(II)EccentrNon-stentedarteryEEMGuidewiresIVUScatheterPlaque+mediaLumenIVUS培训Non-stentedarteryEEMGuidewireStentedArteryEEMLumenStentGuidewireIVUScatheterPlaque+mediaIntimalhyperplasiaIVUS培训StentedArteryEEMLumenStentGuiProximalReferenceLesionSiteDistalReferenceEEMLumenP+MMaxP+MThicknessMinP+MThicknessCa++TheCardiovascular

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InstituteofNewYorkIVUS培训ProximalReferenceLesionDistal03mm12mmProximalReferenceLesionSiteDistalReferenceEEMCSA=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%TheCardiovascular

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InstituteofNewYorkIVUS培训03mm12mmProximalReferenceLesiIn-StentRestenosisIn-stentintimalhyperplasia(IH)oftenappearswithaverylowechogenicityCouldbelessechogenicthanthebloodspeckleAppropriatesystemsettingsarecriticaltovisualizeIH(donot“blackout”center)IVUS培训In-StentRestenosisIn-stentin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VHIVUS培训血管内超声基础和进展一、血管内超声基础IVUS培训LimitationsofCoronaryAngiographyFocalDisease50%Lesion50%LesionDiffuseDiseaseAngiogramSilhouetteIVUS培训LimitationsofCoronaryAngiogAngiographicallySilentDiseaseIn884nativecoronaryarteries,theplaqueburdenintheangiographically“normal”referencesegmentwas51±13%MintzGS,etal.JAmCollCardiol1995;25:1479-1485IVUS培训AngiographicallySilentDiseasCoronaryRemodelingHypothesisCompenatoryExpansion

MaintainsConsistantLumenExpansion

Overcome:LumenNarrowsNormalVesselMinimalCADModerateCADSevereCADIVUS培训CoronaryRemodelingHypothesisProximalreferenceLesionDistalreferenceIntermediateremodelingNegativeremodelingPositiveremodelingNishioka.

JACC1996;27:1571-1576DicotomousClassificationofRemodelingIVUS培训ProximalreferenceLesionDistalABDEff'CFdistalLumenebe'b'LumenPositiveRemodelingNegativeRemodelingcc'distalEEMEEMIVUS培训ABDEff'CFdistalLumenebe'b'LumeLimitationsofCoronaryAngiographyAngiogramSilhouetteCoronaryCross-section75%25%IVUS培训LimitationsofCoronaryAngiogIrregularPlaque/IrregularLumenACross-sectionRAOViewLAOViewBCIVUS培训IrregularPlaque/IrregularLTheCardiovascular

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InstituteofNewYorkIVUSEEMCSA=22.7mm2LumenCSA=16.6mm2Meanlumendiameter=4.6mmQCA9FguidingcatheterReferencediameter=3.12mmIVUS培训TheCardiovascular

ResearchFo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VHIVUS培训血管内超声基础和进展一、血管内超声基础IVUS培训IVUS培训(Fisheretal.CCD1982;8:565-575)Comparisonbetweenpercentstenosisassessmentfromthequalitycontrollabvstheclinicalsite*areaofthesquareisproportionaltothenumberofcaseswiththegivenreadingQClabClinicalsite10001000Ofallthecoronarysegments,theLMistheonewiththegreatestinter-observervariability

PoorinterobserveragreementintheangiographicassessmentofLMCAstenosisintheCASSstudy-IIVUS培训PoorinterobserveragreementintheangiographicassessmentofLMCAstenosisintheCASSstudy-II(Cameronetal.Circulation1983;68:484-489)FivegradesofLMseverity1: 0-24%DS2: 25-49%DS3: 50-74%DS4: 75-89%DS5: 90-100%DS#ofgradesofdifferenceinassessmentofLMseverity0: nodifference+1or-1: 1gradedifference+2or-2: 2gradesofdifference+3or-3: 3gradesofdifference+4or-4: 4gradesofdifferenceClinicalsitevs

QualitycontrolClinicalsitevs

StudyGroupStudyGroupvsQualitycontrolIVUS培训PoorinterobserveragreementiIVUS培训ReferenceLesion10mmLumenCSA=18.3mm2Lumendiameter=5.0mmLumenCSA=3.6mm2Lumendiameter=1.3mmLumenCSA=11.9mm2Lumendiameter=3.5mmPatientwithnormalostialLMCAwhopreviouslyunderwentCABGforpresumedLMCAdiseasePatientwithsevere,butunrecognized,distalLMCAstenosiswhowasreferredforPTCAofLADIVUS培训SuggestedIVUSCriteriafora‘Significant’LMCAStenosisMostIVUSLMCAstudiesshoweitherinsignificantdiseaseorcriticaldisease,onlyaminorityrequirecarefulquantificationLumenCSA<6.0mm2orMLD<3.0mmaresuggestedcriteriaforasignificantLMCAstenosisThesumofthelumenareasofthetwodaughtervessels(LADandLCX,eachofwhichshouldbe4.0mm2)=150%oftheparent(LM)ThesecorrelatedwithanabnormalFFR(JastietalCirculation2004;110:2831-6)IVUS培训SuggestedIVUSCriteriaforaIVUS培训UnusualLesions:IVUSClassificationofAngiographicAneurysmsOf77angiographicaneurysms21(27%)trueaneurysm3(4%)pseudoaneurysm12(16%)complexplaquesorunhealeddissections41(53%)normalsegmentadjacenttooneormorestenosesTrue

AneurysmPSAComplex

PlaqueNormalSitewith

AdjacentStenosesNopriorPCI100626PriorPCI113615(Maeharaetal.AmJCardiol2001;88:365-70)IVUS培训018mmNormalSegmentwithAdjacentStenoses018mmNormalSegmentwithAdjacTrueAneurysmTrueAneurysm2mm010mmPseudoaneurysm2mm010mmPseudoaneurysmRupturedPlaqueRupturedPlaqueProximalDistalLesion5.5mm

MaxLD=3.5mm

MaxLD=3.3mm6mmStentsizingusingIVUSReferencesegmentdiseaseprovidesacushionforoversizingProximalDistalLesion5.5mmMaxThehighpredictivevalue(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%Thehighpredictivevalue(90%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)PredictorsofangiographicresComparisonofIVUS-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%ComparisonofIVUS-measuredmiPeri-StentHaziness:DoubleLumenPeri-StentHaziness:DoubleLuPeri-StentHaziness:PlaqueBurdenTwoOverlappingStentsHazySegmentPeri-StentHaziness:PlaqueBPeri-StentHaziness:CalcificationStentPeri-StentHaziness:CalcificPeri-StentInjury:PlaqueTearUltrasoundSiteStentPeri-StentInjury:PlaqueTear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)何时采用IVUS以达到最佳的DES置入高危患者亚组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VHIVUS培训血管内超声基础和进展一、血管内超声基础IVUS培训IVUSPCwith500MHzandreconstructionsoftwareEliminatetheS-VHSVCRVirtualHistologyTMVolcanoIVUS培训IVUSPCwith500MHzEliminateVirtualHistologyTMVolcanoFIBROTICFIBRO-LIPIDCALCIFICLIPID

COREMEDIALegendClassificationIVUS培训VirtualHistologyTMVolcanoFIBComparisonBetweenVHandHistologyDiagnosticaccuracyNairetal.Circulation2002IVUS培训ComparisonBetweenVHandHistFIBROTICFIBRO-LIPIDICLIPIDIC-CORECALCIFICVirtualHistologyTMEx-VivoValidationIVUS培训FIBROTICFIBRO-LIPIDICL谢谢！IVUS培训IVUS培训血管内超声基础和临床应用进展IVUS培训血管内超声基础和临床应用进展IVUS培训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VHIVUS培训血管内超声基础和进展一、血管内超声基础IVUS培训RotatingElementDriveShaftMulti-elementArrayTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkTherearetwotypesofimagingsystems:Mechanical(rotatingtransducer)andElectronicArrayIVUS培训RotatingElementDriveShaftMulHighfrequencysoundwavesechooffvesselwallsandaresentbacktosystemSystemelectronicsprocessthesignalTheCardiovascular

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InstituteofNewYorkIVUS培训HighfrequencysoundwavesechALA=AxialResolutionL=LateralResolutionTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训ALA=AxialResolutionTheCardLowdynamicrangeHighdynamicrangeTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训LowdynamicrangeHighdynamicIntimaldisease(plaque)isdenseandwillappear‘white’Mediaismadeofhomogeneoussmoothmusclecellsanddoesnotreflectultrasound(appearsdark)Adventitiahas‘sheets’ofcollagenthatreflectalotofultrasound(appearswhite)TheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训Intimaldisease(plaque)isdeTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训TheCardiovascular

ResearchFoCalciumBrightechoes(brighterthantheadventitia)Obstructsthepenetrationofultrasound(acousticshadowing)onlytheleadingedgeisdetectedandthicknesscannotbedetermined.Resultsinreverberations-theoscillationofultrasoundbetweentransducerandcalciumcausingrepeating‘arcs’IVUS培训CalciumBrightechoes(brighter80°SuperficialDeepDeepCalciumisquantifiedbymeasuringthe“arc”itencompassesCalciumisclassifiedbyitslocationwithintheplaqueSuperficialcalciumisclosertothelumenthantotheadventitiaDeepcalciumisclosertotheadventitiathantothelumenTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训80°SuperficialDeepDeepCalciumFibroticPlaqueAsbrightorbrighterthantheadventitia(hyperechoic)MajorityofatheroscleroticlesionsarefibroticVerydense,fibrousplaquesmaycausesomuchacousticshadowingthattheycouldbemisclassifiedascalcifiedIVUS培训FibroticPlaqueAsbrightorbrSoftPlaqueNotasbrightastheadventitia(hypoechoic)“Soft”referstothelowechogenicity,generallyduetohighlipidcontentinamostlycellularlesion.Reducedechodensitymayalsobedueto:necroticzonewithinplaqueintramuralhemorrhagethrombusIVUS培训SoftPlaqueNotasbrightasthVulnerablePlaqueFibrousCapLipidCoreIVUS培训VulnerablePlaqueFibrousCapLiMixedPlaqueIVUS培训MixedPlaqueIVUS培训014mmExampleofThrombusIVUS培训014mmExampleofThrombusIVUS培ExamplesofThrombusIVUS培训ExamplesofThrombusIVUS培训BasicMeasurements(I)Externalelasticmembrane(EEM)crosssectionalarea(CSA)=totalarterialCSA=‘media’areatracingtheboundarybetweenthedarkmediaandthe

brightadventitia(i.e.,theapparentouteredgeofthemediastripe)LumenCSAMaxandminlumendiametersStentCSAMaxandminstentdiametersPlaque+media(P+M)CSA=EEM-LumenCSAinnon-stentedlesions=EEM-stentCSAinstentedlesionsIntimalhyperplasiaCSA=Stent-LumenCSAIVUS培训BasicMeasurements(I)ExternalBasicMeasurements(II)Eccentricity=maximum/minimumP+MthicknessPlaqueBurden(=cross-sectionalnarrowingor%plaquearea)=P+M/EEMCSARemodelingIndex=Lesion/ReferenceEEMCSAAreaStenosis=(Reference-Lesion)/ReferenceLumenCSAArcofcalciumLesionlengthsmeasuredusingmotorizedtransducerpullback,ideallyat0.5mm/secIVUS培训BasicMeasurements(II)EccentrNon-stentedarteryEEMGuidewiresIVUScatheterPlaque+mediaLumenIVUS培训Non-stentedarteryEEMGuidewireStentedArteryEEMLumenStentGuidewireIVUScatheterPlaque+mediaIntimalhyperplasiaIVUS培训StentedArteryEEMLumenStentGuiProximalReferenceLesionSiteDistalReferenceEEMLumenP+MMaxP+MThicknessMinP+MThicknessCa++TheCardiovascular

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InstituteofNewYorkIVUS培训ProximalReferenceLesionDistal03mm12mmProximalReferenceLesionSiteDistalReferenceEEMCSA=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%TheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUS培训03mm12mmProximalReferenceLesiIn-StentRestenosisIn-stentintimalhyperplasia(IH)oftenappearswithaverylowechogenicityCouldbelessechogenicthanthebloodspeckleAppropriatesystemsettingsarecriticaltovisualizeIH(donot“blackout”center)IVUS培训In-StentRestenosisIn-stentin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VHIVUS培训血管内超声基础和进展一、血管内超声基础IVUS培训LimitationsofCoronaryAngiographyFocalDisease50%Lesion50%LesionDiffuseDiseaseAngiogramSilhouetteIVUS培训LimitationsofCoronaryAngiogAngiographicallySilentDiseaseIn884nativecoronaryarteries,theplaqueburdenintheangiographically“normal”referencesegmentwas51±13%MintzGS,etal.JAmCollCardiol1995;25:1479-1485IVUS培训AngiographicallySilentDiseasCoronaryRemodelingHypothesisCompenatoryExpansion

MaintainsConsistantLumenExpansion

Overcome:LumenNarrowsNormalVesselMinimalCADModerateCADSevereCADIVUS培训CoronaryRemodelingHypothesisProximalreferenceLesionDistalreferenceIntermediateremodelingNegativeremodelingPositiveremodelingNishioka.

JACC1996;27:1571-1576DicotomousClassificationofRemodelingIVUS培训ProximalreferenceLesionDistalABDEff'CFdistalLumenebe'b'LumenPositiveRemodelingNegativeRemodelingcc'distalEEMEEMIVUS培训ABDEff'CFdistalLumenebe'b'LumeLimitationsofCoronaryAngiographyAngiogramSilhouetteCoronaryCross-section75%25%IVUS培训LimitationsofCoronaryAngiogIrregularPlaque/IrregularLumenACross-sectionRAOViewLAOViewBCIVUS培训IrregularPlaque/IrregularLTheCardiovascular

ResearchFoundationLenoxHillHeartandVascular

InstituteofNewYorkIVUSEEMCSA=22.7mm2LumenCSA=16.6mm2Meanlumendiameter=4.6mmQCA9FguidingcatheterReferencediameter=3.12mmIVUS培训