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RCABasicAnatomyOriginrightaorticsinus(loweroriginthanLCA)CourseDownrightAVgroovetowardcruxoftheheart,givesoffPDA(85%)fromwhichseptalsarise,continuesinLAVgroovegivingoffposteriorLVbranches(posterolaterals).PDAmayoriginatemoreproximally,bifurcateearlyorbesmallwithpartof“itsterritory〞suppliedbyanacutemarginalbranch.RCAOtherBranchesConusArtery(圆锥支)

usuallyveryproximal;coursesanteriorlyandupwardovertheRVoutflowtracttowardtheLAD.MaybeanimportantSourceofcollaterals.SANodalArtery(窦房结动脉)(~60%)usually2ndbranchofRCA-coursesobliquelybackwardthroughuperportionofaterialseptumandanteromedialwalloftheRA-suppliesSAnode,usuallyRAandsometimesLA

RCAOtherBranchesPDA(后降支)

Suppliesinferiorwall,ventricularseptum,posteromedialpapillarymuscle.AVNodalArtery(房室结支)

Arisesatornearcrux;suppliesAVnode.Rightventricular(AcutemarginalBranches锐缘支)

ArisefrommidRCA;SupplyanteriorRV;maybeacollateralsource.RCAOptimalView(s)LAO(30)Cranial(30)particularlyfordistalbifurcation(APcranialmaybebetter).RAOmainshaft;cranialenhancesdistalvesselsandveryproximal;caudalmayhelpwithshepherd’scrook.LateralbifurcationswithRVbranches-distalbifurcation,particularlywithcranial.RCA圆锥支窦房结支右室支锐缘支后降支后侧支LCALMOptimalViewsLAOcaudalandcranial;AP-caudal,cranialorflat.Limitviews.MayneedIVUSLADCourse

downtheanteriorinterventriculargroove-usuallyreachesapex.In22%ofcasesdoesnotreachapexLCABranches

septalsanddiagonals-supplylateralwallofLV,anterolateralpapillarymuscle;37%havemedianramus(courseslike1stdiagonal).LAD

suppliesanterolateral,apexandseptum;~45%-55%ofleftventricle.LCXBranchesobtusemarginal,posterolaterals-supplyposterolateralLV,anterolteralpapillarymuscles.SAnodeartery38%Supplies15%-25%ofLV,unlessdominant(supplies40-50%ofLV).APCaudalviewofLCAAPCranialLAOCranialViewLAOCaudalViewAHA/ACC冠脉病变分类A型病变散在病变(长度<10mm)向心型狭窄容易插管到病灶部位各节段间成角<450血管外表较平滑无钙化或很轻度钙化不是管腔完全闭塞狭窄部位不在血管开口处无重要分支狭窄管腔内无血栓B型病变病变成管状(10-20mm).偏心型狭窄近端节段中度弯曲各节段间成角450-900血管外表不光滑中度或重度钙化管腔完全闭塞<3个月狭窄部位在开口处血管分叉处需要2根导引钢丝管腔内有血栓C型病变弥漫性病变(>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,堵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去除，心肌显影在开始下一个造影序列〔间隔~30秒〕时