冠状动脉造影abc-课件

冠状冠状动脉造影脉造影abc pptabc ppt课件件冠状动脉造影abc ppt课件冠状动脉造影abc ppt课件11959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1959年Mason Sones 利用特制的尖端呈弧形的造影2 2冠脉造影冠脉造影5050余年的历程余年的历程!CA introduced by F.Mason Sones,Jr,MD(CA introduced by F.Mason Sones,Jr,MD(首次冠脉造影首次冠脉造影首次冠脉造影首次冠脉造影)The first human studies-severity and extent of CAD(The first human studies-severity and extent of CAD(首个人体研究首个人体研究首个人体研究首个人体研究)Earliest natural history studies of proven CAD Earliest natural history studies of proven CAD Dynamic visualization of LV performance(Dynamic visualization of LV performance(左室造影左室造影左室造影左室造影)Demonstration of prompt and complete revascularization by CABGDemonstration of prompt and complete revascularization by CABG Refinement of natural history studies of unoperated CAD patients Refinement of natural history studies of unoperated CAD patients Discovery of the benefit of CABG vs.Med Rx in subsets of patients Discovery of the benefit of CABG vs.Med Rx in subsets of patients Delineation of coronary vasospasm and PrinzmetalDelineation of coronary vasospasm and Prinzmetal s angina(s angina(冠脉冠脉冠脉冠脉痉挛痉挛)Significance of coronary pathoanatomy(ulceration,thrombus,Significance of coronary pathoanatomy(ulceration,thrombus,dissection,aneurysm,muscle bridge,collateral vessels)dissection,aneurysm,muscle bridge,collateral vessels)Introduction of PTCA and delineation of restenosis(PTCAIntroduction of PTCA and delineation of restenosis(PTCA及再狭窄及再狭窄及再狭窄及再狭窄)First angiographic evidence of clot lysis in a coronary vesselFirst angiographic evidence of clot lysis in a coronary vessel1950s1960s1970sRyan Circulation 2002,106:752-756冠脉造影50余年的历程!CA introduced by F3 3冠脉造影冠脉造影5050余年的历程余年的历程!Thrombolytic era,with the demonstration of spontaneous fibrinolysis Thrombolytic era,with the demonstration of spontaneous fibrinolysis during 24 hrs of acute occlusions(during 24 hrs of acute occlusions(心梗心梗心梗心梗2424小小小小时时时时内的内的内的内的血栓血栓血栓血栓自溶自溶自溶自溶)Plaque regression studies uncovering the clinical benefits of statin Plaque regression studies uncovering the clinical benefits of statin therapy(therapy(他汀治他汀治他汀治他汀治疗疗斑斑斑斑块块消褪消褪消褪消褪)Delineation of the pathogenesis of AMI from studies outlining Delineation of the pathogenesis of AMI from studies outlining angiographic progression to MI(AMIangiographic progression to MI(AMI的的的的发发病机制病机制病机制病机制)Estimates of coronary flow using TFG and TFCEstimates of coronary flow using TFG and TFC Comparisons of PCI vs CABG for revascularization outcomesComparisons of PCI vs CABG for revascularization outcomes Stents era Stents era Myocardial blush(Myocardial blush(心肌染色分心肌染色分心肌染色分心肌染色分级级)Brachytherapy,late stent thrombosis,and pharmocotherapy Brachytherapy,late stent thrombosis,and pharmocotherapy The coronary catheter and newer imaging devices(intravascular The coronary catheter and newer imaging devices(intravascular ultrasound,MRI)ultrasound,MRI)1980s1990sRyan Circulation 2002,106:752-7562013冠脉造影50余年的历程!Thrombolytic era,4 4冠脉造影冠脉造影股动脉及桡动脉路径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5 5解剖学解剖学桡动脉脉掌浅弓掌浅弓尺尺动脉脉解剖学桡动脉掌浅弓尺动脉6 6Allen Allen 试验试验Allen 试验7 7Allen 试验解解读Allen 试验解读8 8Assement of ulnar arch by oxymetrynAllens test is subjective and difficult to interpretnBarbeau scoreBarbeau.G et al;Am Heart J 2004;147:489932 minAssement of ulnar arch by oxym9 9Barbeau.G et al;Am Heart J 2004;147:48993NOBarbeau scoreBarbeau.G et al;Am Heart J 21010冠脉造影冠脉造影 导管导管JudkinsAmplatzTiger 导管管JR4 导管管冠脉造影 导管JudkinsAmplatzTiger 导管J1111冠脉解剖学冠脉解剖学左主干左主干(LM)左前降支左前降支(LAD)对角支对角支(D1,D2)间隔支间隔支(septal)LADD1SeptalD2LMSRCAPLVINFPDAAM冠脉解剖学左主干(LM)LADD1SeptalD2LMSR1212左前降支左前降支 Radiographics 2007;27:1569-1582左前降支 Radiographics 2007;27:1561313Radiographics 2007;27:1569-1582右冠状右冠状动动脉脉Marginal branchConus branchMarginal branchRadiographics 2007;27:1569-1581414回旋支回旋支回旋支回旋支(Cx)钝缘支钝缘支(OM1,OM2)OM1CXOM2LAD回旋支OM1CXOM2LAD1515 Radiographics 2007;27:1569-1582回旋支回旋支OMOMLMSCXCXOM Radiographics 2007;27:1569-151616Radiographics 2007;27:1569-1582中中间间支支IMCXLMSRadiographics 2007;27:1569-1581717 右右右右优势优势:This occurs when the This occurs when the descending,inferior,and descending,inferior,and posterior branches all arise posterior branches all arise from the RCA.from the RCA.均衡型均衡型均衡型均衡型:This occurs when only the This occurs when only the descending branch arises descending branch arises from the RCA,while the from the RCA,while the inferior and posterior inferior and posterior branches arise from the CX.branches arise from the CX.左左左左优势优势:This occurs when all three This occurs when all three branches arise from the CX.branches arise from the CX.冠脉冠脉优势优势型型后侧支(PL)后降支(PD)右优势:冠脉优势型后侧支(PL)后降支(PD)1818冠脉起源异常冠脉起源异常左主干起源于右冠窦radiologyassistant.nl/en/48275120e2ed5冠脉起源异常左主干起源于右冠窦radiologyassist1919心肌心肌桥桥Myocardial bridge in LADradiologyassistant.nl/en/48275120e2ed5A myocardial bridge occurs when one of the coronary arteries tunnels through the myocardium rather than resting on top of the myocardium心肌桥Myocardial bridge in LADrad2020冠脉造影提供的信息冠脉造影提供的信息定量冠脉造影分析定量冠脉造影分析冠脉血流冠脉血流心肌灌注心肌灌注其他特性其他特性:钙钙化化化化血栓血栓血栓血栓溃疡溃疡夹层夹层动动脉瘤脉瘤脉瘤脉瘤钙化冠脉造影提供的信息定量冠脉造影分析钙化2121定量冠脉造影分析定量冠脉造影分析(QCA)1 1近端参考血管直径近端参考血管直径近端参考血管直径近端参考血管直径:2.2.最小直径最小直径最小直径最小直径:3.3.远远远远端参考血管直径端参考血管直径端参考血管直径端参考血管直径:4.4.病病病病变长变长度度度度:直径狭窄直径狭窄直径狭窄直径狭窄:1234定量冠脉造影分析(QCA)1近端参考血管直径:12342222病病变特征描述特征描述 偏心偏心偏心偏心:The plaque is twice as large on The plaque is twice as large on one side of the arterial border one side of the arterial border compared with the pared with the other.钙钙化化化化:Readily apparent densities:Readily apparent densities noted within the apparent vascular noted within the apparent vascular wall at the site of the stenosis.wall at the site of the stenosis.弥漫弥漫弥漫弥漫:Lesion is 20 mm in length.Lesion is 20 mm in length.分叉分叉分叉分叉:Atherosclerotic plaque involves Atherosclerotic plaque involves the origin of two separate arteries.the origin of two separate arteries.开口开口开口开口:Lesion beginning within 3-5 mm Lesion beginning within 3-5 mm of the origin of a major epicardial of the origin of a major epicardial artery.artery.BifurcationOstial病变特征描述偏心:The plaque is twice 2323TIMI 血流分血流分级TIMI Flow grade:TIMI Flow grade:Classification of TFGClassification of TFG Grade 0Grade 0,no perfusion no perfusion Grade 1Grade 1,penetration penetration without perfusion without perfusion Grade 2Grade 2,partial perfusion,partial perfusion Grade 3Grade 3,complete complete perfusion perfusion TFG0TFG1TFG2TFG3TIMI 血流分级TIMI Flow grade:TFG0T2424TIMI 计帧TIMI Frame Count:TIMI Frame Count:Gibson C M et al.Circulation 1999;99:1945-1950Gibson 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(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 计帧TIMI Frame Count:Gibson2525TIMI 心肌灌注分心肌灌注分级TIMI Myocardial Perfusion Grade:TIMI Myocardial Perfusion Grade:TMPG 0TMPG 0:Failure of dye to enter the Failure of dye to enter the microvasculature.microvasculature.TMPG 1TMPG 1:Dye slowly enters but fails to Dye slowly enters but fails to exit the microvasculature.exit the microvasculature.TMPG 2TMPG 2:Delayed entry and exit of Delayed entry and exit of dye from the microvasculature.dye from the microvasculature.TMPG 3TMPG 3:Normal entry and exit of dye Normal entry and exit of dye from the microvasculature.from the microvasculature.Gibson et al.Circulation 2000;101:125-130TIMI 心肌灌注分级TIMI Myocardial Per262627|MDT ConfidentialUC201204429EE直接直接PCIPCI后，虽然心外膜冠状动脉血流率高，但再灌注未成功后，虽然心外膜冠状动脉血流率高，但再灌注未成功Brener SJ et al.Circ CV Interv.2012;5:563-9Farkouh ME et al.Circ CV Interv.2013;6:216-23心肌灌注分级TIMI血流ST段回落直接PCI后，虽然心外膜冠状动脉血流率高，但再灌注未成功Br28|MDT ConfidentialUC201204429EE镜下远端栓子和无复流TIMI 3 级血流级血流 无微血管灌注无微血管灌注Henriques JPS et al.EHJ 2002;23:1112-7镜下远端栓子和无复流TIMI 3 级血流 无微血管灌注He血栓分血栓分级级 Grade 0Grade 0:No cine-angiographic characteristics of thrombus present.No cine-angiographic characteristics of thrombus present.Grade 1:Grade 1:Hazy,possible thrombus present.Angiography Hazy,possible thrombus present.Angiography demonstrates characteristics such as reduced contrast density,demonstrates characteristics such as reduced contrast density,haziness,irregular lesion contour,or a smooth convex meniscus at haziness,irregular lesion contour,or a smooth convex meniscus at the site of total occlusion suggestive but not diagnostic of thrombus.the site of total occlusion suggestive but not diagnostic of thrombus.Grade 2:Grade 2:Thrombus present small size:Definite thrombus with Thrombus present small size:Definite thrombus with greatest dimensions less than or equal to 1/2 vessel diameter.greatest dimensions less than or equal to 1/2 vessel diameter.Grade 3:Grade 3:Thrombus present moderate size:Definite thrombus but Thrombus present moderate size:Definite thrombus but with greatest linear dimension greater than 1/2 but less than 2 vessel with greatest linear dimension greater than 1/2 but less than 2 vessel diameters.diameters.Grade 4:Grade 4:Thrombus present large size:As in Grade 3 but with the Thrombus present large size:As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameters.largest dimension greater than or equal to 2 vessel diameters.Grade 5Grade 5:Recent total occlusion,can involve some collateralization Recent total occlusion,can involve some collateralization but usually does not involve extensive collateralization,tends to have but usually does not involve extensive collateralization,tends to have a a“beakbeak”shape and a hazy edge or appearance of distinct thrombus.shape and a hazy edge or appearance of distinct thrombus.Grade 6:Grade 6:Chronic total occlusion,usually involving Chronic total occlusion,usually involving extensiveextensive collateralization,tends to have distinct,blunt cutoff/edge and will collateralization,tends to have distinct,blunt cutoff/edge and will generally clot up to the nearest proximal side branch.generally clot up to the nearest proximal side branch.Gibson CM et al.Circulation.2001;103:2550-2554Grade 5 thrombusGrade 4 thrombus血栓分级Grade 0:No cine-angiogra2929动脉瘤脉瘤 A localized arterial widening(dilatation)A localized arterial widening(dilatation)that usually manifests itself as a bulge.that usually manifests itself as a bulge.Its presence may lead to weakening of Its presence may lead to weakening of the wall and eventual rupture.the wall and eventual rupture.Grade 0:Grade 0:None no ectasia present.None no ectasia present.Grade 1:Grade 1:Ectasia visual assessment Ectasia visual assessment of ectasia 1&1&1.5 times assessment of an aneurysm 1.5 times the normal artery diameter located the normal artery diameter located anywhere in the culprit artery.anywhere in the culprit artery.动脉瘤A localized arterial wideni3030病病变变复复杂杂程度程度AHA Task Force Definition as modified by Ellis et al:AHA Task Force Definition as modified by Ellis et al:Type AType A:10 mm,discrete,concentric readily accessible,45 degree 10 mm,discrete,concentric readily accessible,45 degree angle smooth contour,little or no calcification,less than totally angle smooth contour,little or no calcification,less than totally occluded,not ostial,no major side branch involvement,absence of occluded,not ostial,no major side branch involvement,absence of thrombus.thrombus.Type B1Type B1:One of the following characteristics:One of the following characteristics:Type B2Type B2:Two or more of the following characteristics:10-20 mm,Two or more of the following characteristics:10-20 mm,eccentric,moderate tortuosity of proximal segment,irregular contour,eccentric,moderate tortuosity of proximal segment,irregular contour,presence of any thrombus grade,moderate or heavy calcification,total presence of any thrombus grade,moderate or heavy calcification,total occlusion 3 months old,ostial lesion or bifurcation lesion.occlusion 3 months old and/or bridging collaterals,total occlusion 3 months old and/or bridging collaterals,inability to inability to protect major side branches,or degenerated vein graft with friable protect major side branches,or degenerated vein graft with friable lesions.lesions.病变复杂程度AHA Task Force Definitio3131分叉病分叉病变变:Medina分型分型1,1,1分叉病变:Medina分型1,1,13232夹层分分级An intraluminal filling defect or flap associated An intraluminal filling defect or flap associated with a hazy,ground-glass appearance.This with a hazy,ground-glass appearance.This category is sub-classified using the NHLBI system category is sub-classified using the NHLBI system for grading dissection types:for grading dissection types:Type AType A:Radiolucent areas within the coronary Radiolucent areas within the coronary lumen during contrast injection,with minimal or lumen during contrast injection,with minimal or no persistence of contrast after dye has cleared.no persistence of contrast after dye has cleared.Type BType B:Parallel tracts or double lumen separated:Parallel tracts or double lumen separated by a radiolucent area during contrast injection,by a radiolucent area during contrast injection,with minimal or no persistence after dye has with minimal or no persistence after dye has cleared.cleared.Type CType C:Contrast outside the coronary lumen,with:Contrast outside the coronary lumen,with persistence of contrast in the area after dye has persistence of contrast in the area after dye has cleared.cleared.Type DType D:Spiral luminal filling defects frequently:Spiral luminal filling defects frequently with extensive contrast staining of the vessel.with extensive contrast staining of the vessel.Type EType E:New persistent filling defects that may be:New persistent filling defects that may be caused by thrombus.caused by thrombus.Type FType F:These are non A E dissection types that:These are non A E dissection types that lead to impaired flow or total occlusion of the lead to impaired flow or total occlusion of the coronary artery.coronary artery.Dissection-Type DDissection flap post POBA in a heavily calcified lesion-Type C夹层分级An intraluminal filling d3333其他其他 穿孔穿孔穿孔穿孔:Presence of extra-luminal contrast that Presence of extra-luminal contrast that develops develops during the procedure.during the procedure.分支分支分支分支丢丢失失失失:The development of TIMI grade 0 or 1 flow in a The development of TIMI grade 0 or 1 flow in a side branch that was 1.5 mm in diameter prior side branch that was 1.5 mm in diameter prior to the procedure and was initially patent with to the procedure and was initially patent with TIMI grade 2 or 3 flow.TIMI grade 2 or 3 flow.手手手手术术成果成果成果成果:Complete success:If the post-procedure visual Complete success:If the post-procedure visual residual stenosis is 50%with no decrement in residual stenosis is 50%50%residual stenosis by visual assessment residual stenosis by visual assessment oror if if TIMI Grade 2 Flow is attained(this includes TIMI Grade 2 Flow is attained(this includes TFG 2.5).TFG 2.5).Failure:If there is a persistent total occlusion,Failure:If there is a persistent total occlusion,if the lesion cannot be crossed,or if there is if the lesion cannot be crossed,or if there is persistent abrupt closure.persistent abrupt closure.PerforationPerforationPrePost其他穿孔:PerforationPerforationPr3434其他其他远端栓塞端栓塞:The appearance of an abrupt cutoff in the The appearance of an abrupt cutoff in the distal vessel following PTCA.distal vessel following PTCA.无复流无复流:Markedly delayed flow down the artery Markedly delayed flow down the artery with minimal residual stenosis.with minimal residual stenosis.其他远端栓塞:3535侧枝循枝循环 Partial:Partial:Minimal collaterals Minimal collaterals present.Evidence of present.Evidence of minimal to partial filling minimal to partial filling of the recipient branch of the recipient branch epicardial epicardial arteries/infarct region.arteries/infarct region.Complete:Complete:Well-developed Well-developed collaterals.Evidence of collaterals.Evidence of collateral circulation collateral circulation with near complete to with near complete to complete filling of the complete filling of the recipient major recipient major epicardial artery/infarct epicardial artery/infarct region.region.LADRCA侧枝循环Partial:LADRCA3636支架内再狭窄支架内再狭窄IVUS interrogation has identified IH as the main cause of ISREur Heart J(2003)24(2):138-150.(2003)24(2):138-150.支架内再狭窄IVUS interrogation has i3737支架内血栓支架内血栓IVUS provides an attractive technique to characterise fully the pattern of stent thrombosis,to identify readily the underlying mechanical predisposing factors,and to guide repeated coronary interventionsHeart.2004 December;90(12):14551459支架内血栓IVUS provides an attracti3838AEDCBFCase 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 cleared 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).斑斑斑斑块块破裂破裂破裂破裂,血栓形成血栓形成血栓形成血栓形成/急性急性急性急性STST段抬高心梗段抬高心梗段抬高心梗段抬高心梗Cardiogenic shock in women.Kunadian et al.ICCL 2012Ruptured plaque visible on angioAEDCBFCase example of a 59 yea3939谢谢！谢谢！40