冠狀動脈造影abc教學課件

1、冠心病介入診療-ABC第1頁，共40頁。1929年,德國醫(yī)生Wenner Forssmann在自己身上進行了人類首例心導管檢查術. 他將導管經左肘前靜脈,鎖骨下靜脈,上腔靜脈送入右心房,并拍了醫(yī)學史上第一張右心導管胸片,從此揭開了介入心臟病學的序幕.第2頁，共40頁。1959年Mason Sones 利用特制的尖端呈弧形的造影導管,經肱動脈送入主動脈根部進行主動脈造影,無意中將造影劑直接注入右冠狀動脈內使其清晰顯影,這一偶然事件開創(chuàng)了冠脈介入診斷技術的新紀元第3頁，共40頁。冠脈造影50余年的歷程!CA introduced by F. Mason Sones, Jr, MD (首次冠脈造影)

2、The first human studies- severity and extent of CAD (首個人體研究)Earliest natural history studies of proven CAD Dynamic visualization of LV performance (左室造影)Demonstration of prompt and complete revascularization by CABGRefinement of natural history studies of unoperated CAD patients Discovery of the ben

3、efit of CABG vs. Med Rx in subsets of patients Delineation of coronary vasospasm and Prinzmetals angina(冠脈痙攣)Significance of coronary pathoanatomy (ulceration, thrombus, dissection, aneurysm, muscle bridge, collateral vessels) Introduction of PTCA and delineation of restenosis (PTCA及再狹窄)First angiog

4、raphic evidence of clot lysis in a coronary vessel1950s1960s1970sRyan Circulation 2002, 106:752-756第4頁，共40頁。冠脈造影50余年的歷程!Thrombolytic era, with the demonstration of spontaneous fibrinolysis during 24 hrs of acute occlusions (心梗24小時內的血栓自溶)Plaque regression studies uncovering the clinical benefits of s

5、tatin therapy (他汀治療斑塊消褪)Delineation of the pathogenesis of AMI from studies outlining angiographic progression to MI (AMI的發(fā)病機制)Estimates of coronary flow using TFG and TFCComparisons of PCI vs CABG for revascularization outcomesStents era Myocardial blush (心肌染色分級)Brachytherapy, late stent thrombosis

6、, and pharmocotherapy The coronary catheter and newer imaging devices (intravascular ultrasound, MRI)1980s1990sRyan Circulation 2002, 106:752-7562013第5頁，共40頁。冠脈造影股動脈及橈動脈路徑股神經股總動脈股靜脈穿刺位置股骨頭腹股溝韌帶尺動脈橈動脈肱動脈第6頁，共40頁。解剖學橈動脈掌淺弓尺動脈第7頁，共40頁。Allen 試驗第8頁，共40頁。Allen 試驗解讀第9頁，共40頁。Assement of ulnar arch by oxymet

7、ryAllens test is subjective and difficult to interpretBarbeau scoreBarbeau. G et al; Am Heart J 2004;147:489932 min第10頁，共40頁。Barbeau. G et al; Am Heart J 2004;147:48993NOBarbeau score第11頁，共40頁。冠脈造影 導管JudkinsAmplatzTiger 導管JR4 導管第12頁，共40頁。冠脈解剖學左主干(LM) 左前降支(LAD) 對角支(D1, D2) 間隔支(septal) LADD1SeptalD2LM

8、SRCAPLVINFPDAAM第13頁，共40頁。左前降支 Radiographics 2007;27:1569-1582第14頁，共40頁。Radiographics 2007;27:1569-1582右冠狀動脈Marginal branchConus branchMarginal branch第15頁，共40頁。回旋支回旋支 (Cx) 鈍緣支 (OM1, OM2)OM1CXOM2LAD第16頁，共40頁。 Radiographics 2007;27:1569-1582回旋支OMOMLMSCXCXOM第17頁，共40頁。Radiographics 2007;27:1569-1582中間支IM

9、CXLMS第18頁，共40頁。右優(yōu)勢: This occurs when the descending, inferior, and posterior branches 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.左優(yōu)勢: This occurs when all three branches arise from the CX.冠脈

10、優(yōu)勢型后側支(PL)后降支(PD)第19頁，共40頁。冠脈起源異常左主干起源于右冠竇http:/www.radiologyassistant.nl/en/48275120e2ed5第20頁，共40頁。心肌橋Myocardial bridge in LADhttp:/www.radiologyassistant.nl/en/48275120e2ed5A myocardial bridge occurs when one of the coronary arteries tunnels through the myocardium rather than resting on top of the

11、 myocardium第21頁，共40頁。冠脈造影提供的信息定量冠脈造影分析冠脈血流心肌灌注其他特性:鈣化血栓潰瘍夾層動脈瘤鈣化第22頁，共40頁。定量冠脈造影分析(QCA)1近端參考血管直徑: 2. 最小直徑: 3. 遠端參考血管直徑: 4. 病變長度: 直徑狹窄: 1234第23頁，共40頁。病變特征描述偏心: The plaque is twice as large on one side of the arterial border compared with the other. 鈣化: Readily apparent densities noted within the appa

12、rent vascular wall at the site of the stenosis.彌漫: Lesion is 20 mm in length.分叉: Atherosclerotic plaque involves the origin of two separate arteries. 開口: Lesion beginning within 3-5 mm of the origin of a major epicardial artery.BifurcationOstial第24頁，共40頁。TIMI 血流分級TIMI Flow grade:Classification of TF

13、GGrade 0, no perfusion Grade 1, penetration without perfusion Grade 2, partial perfusion Grade 3, complete perfusion TFG0TFG1TFG2TFG3第25頁，共40頁。TIMI 計幀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

14、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

15、/s) and dividing by the TFC. 第26頁，共40頁。TIMI 心肌灌注分級TIMI Myocardial Perfusion Grade:TMPG 0: Failure of dye to enter 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

16、 from the microvasculature.Gibson et al. Circulation 2000; 101:125-130第27頁，共40頁。直接PCI后，雖然心外膜冠狀動脈血流率高，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心肌灌注分級TIMI血流ST段回落第28頁，共40頁。鏡下遠端栓子和無復流TIMI 3 級血流 無微血管灌注Henriques JPS et al. EHJ 2002;23:1112-7第29頁，共4

17、0頁。血栓分級Grade 0: No cine-angiographic characteristics of thrombus present.Grade 1: Hazy, possible thrombus present. Angiography demonstrates characteristics such as reduced contrast density, haziness, irregular lesion contour, or a smooth convex meniscus at the site of total occlusion suggestive but

18、not diagnostic of thrombus.Grade 2: Thrombus present small size: Definite thrombus with greatest dimensions less than or 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

19、4: Thrombus present large size: As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameters.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 appea

20、rance of distinct thrombus.Grade 6: Chronic total occlusion, usually involving extensive collateralization, tends to have distinct, blunt cutoff/edge and will generally clot up to the nearest proximal side branch.Gibson CM et al. Circulation. 2001;103:2550-2554Grade 5 thrombusGrade 4 thrombus第30頁，共4

21、0頁。動脈瘤A localized arterial widening (dilatation) that usually manifests itself as a bulge. Its presence may lead to weakening 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 t

22、he culprit artery.第31頁，共40頁。病變復雜程度AHA Task Force Definition as modified by Ellis et al:Type A: 10 mm, discrete, concentric readily accessible, 45 degree angle smooth contour, little or no calcification, less than totally occluded, not ostial, no major side branch involvement, absence of thrombus.Typ

23、e B1: One of the following characteristics:Type B2: Two or more of the following characteristics: 10-20 mm, eccentric, moderate tortuosity of proximal segment, irregular contour, presence of any thrombus grade, moderate or heavy calcification, total occlusion 3 months old and/or bridging collaterals

24、, inability to protect major side branches, or degenerated vein graft with friable lesions.第32頁，共40頁。分叉病變: Medina分型1,1,1第33頁，共40頁。夾層分級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

25、types:Type 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 cleare

26、d.Type 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

27、 E dissection types that lead to impaired flow or total occlusion of the coronary artery.Dissection-Type DDissection flap post POBA in a heavily calcified lesion- Type C第34頁，共40頁。其他穿孔: Presence of extra-luminal contrast that develops during the procedure.分支丟失: The development of TIMI grade 0 or 1 fl

28、ow in a side branch that was 1.5 mm in diameter prior to the procedure and was initially patent with TIMI grade 2 or 3 flow.手術成果: 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)

29、.Failure: If there is a persistent total occlusion, if the lesion cannot be crossed, or if there is persistent abrupt closure.PerforationPerforationPrePost第35頁，共40頁。其他遠端栓塞: The appearance of an abrupt cutoff in the distal vessel following PTCA. 無復流: Markedly delayed flow down the artery with minimal

30、 residual stenosis.第36頁，共40頁。側枝循環(huán)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 e