冠狀動脈造影ABC

冠心病介入診療--ABC1929年,德國醫(yī)生WennerForssmann在自己身上進行了人類首例心導管檢查術.他將導管經(jīng)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.1959年MasonSones

利用特制的尖端呈弧形的造影導管,經(jīng)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(nèi)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冠脈造影50余年的歷程!CAintroducedbyF.MasonSones,Jr,MD(首次冠脈造影)

Thefirsthumanstudies-severityandextentofCAD(首個人體研究)EarliestnaturalhistorystudiesofprovenCAD????DynamicvisualizationofLVperformance(左室造影)

DemonstrationofpromptandcompleterevascularizationbyCABGRefinementofnaturalhistorystudiesofunoperatedCADpatientsDiscoveryofthebenefitofCABGvs.MedRxinsubsetsofpatientsDelineationofcoronaryvasospasmandPrinzmetal’sangina(冠脈痙攣)Significanceofcoronarypathoanatomy(ulceration,thrombus,dissection,aneurysm,musclebridge,collateralvessels)IntroductionofPTCAanddelineationofrestenosis(PTCA及再狹窄)Firstangiographicevidenceofclotlysisinacoronaryvessel1950s1960s1970sRyanCirculation2002,106:752-756冠脈造影50余年的歷程!Thrombolyticera,withthedemonstrationofspontaneousfibrinolysisduring24hrsofacuteocclusions(心梗24小時內(nèi)的血栓自溶)Plaqueregressionstudiesuncoveringtheclinicalbenefitsofstatintherapy(他汀治療斑塊消褪)DelineationofthepathogenesisofAMIfromstudiesoutliningangiographicprogressiontoMI(AMI的發(fā)病機制)EstimatesofcoronaryflowusingTFGandTFCComparisonsofPCIvsCABGforrevascularizationoutcomesStentseraMyocardialblush(心肌染色分級)Brachytherapy,latestentthrombosis,andpharmocotherapyThecoronarycatheterandnewerimagingdevices(intravascularultrasound,MRI)1980s1990sRyanCirculation2002,106:752-7562013冠脈造影

股動脈及橈動脈路徑股神經(jīng)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解剖學橈動脈掌淺弓尺動脈Allen試驗Allen試驗解讀AssementofulnararchbyoxymetryAllen’stestissubjectiveanddifficulttointerpretBarbeauscoreBarbeau.Getal;AmHeartJ2004;147:489–932minBarbeau.Getal;AmHeartJ2004;147:489–93NOBarbeauscore冠脈造影

導管JudkinsAmplatzTiger導管JR4導管冠脈解剖學左主干(LM)左前降支(LAD)對角支(D1,D2)間隔支(septal)LADD1SeptalD2LMSRCAPLVINFPDAAM左前降支Radiographics2007;27:1569-1582Radiographics2007;27:1569-1582右冠狀動脈MarginalbranchConusbranchMarginalbranch回旋支回旋支(Cx)鈍緣支(OM1,OM2)OM1CXOM2LADRadiographics2007;27:1569-1582回旋支OMOMLMSCXCXOMRadiographics2007;27:1569-1582中間支IMCXLMS右優(yōu)勢:

Thisoccurswhenthedescending,inferior,andposteriorbranchesallarisefromtheRCA.均衡型:

ThisoccurswhenonlythedescendingbrancharisesfromtheRCA,whiletheinferiorandposteriorbranchesarisefromtheCX.左優(yōu)勢:

ThisoccurswhenallthreebranchesarisefromtheCX.冠脈優(yōu)勢型后側支(PL)后降支(PD)冠脈起源異常左主干起源于右冠竇http://www.radiologyassistant.nl/en/48275120e2ed5心肌橋MyocardialbridgeinLADhttp://www.radiologyassistant.nl/en/48275120e2ed5Amyocardialbridgeoccurswhenoneofthecoronaryarteriestunnelsthroughthemyocardiumratherthanrestingontopofthemyocardium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病變特征描述偏心:Theplaqueistwiceaslargeononesideofthearterialbordercomparedwiththeother.鈣化:Readilyapparentdensitiesnotedwithintheapparentvascularwallatthesiteofthestenosis.彌漫:Lesionis≥20mminlength.分叉:Atheroscleroticplaqueinvolvestheoriginoftwoseparatearteries.開口:

Lesionbeginningwithin3-5mmoftheoriginofamajorepicardialartery.BifurcationOstialTIMI血流分級TIMIFlowgrade:ClassificationofTFGGrade0,noperfusionGrade1,penetrationwithoutperfusionGrade2,partialperfusionGrade3,completeperfusionTFG0TFG1TFG2TFG3TIMI計幀TIMIFrameCount:GibsonCMetal.Circulation1999;99:1945-1950GibsonetalfoundameancorrectedTFC(cTFC)fornormalcoronaryarteriesof21

3.1frames,yieldinga95%confidenceintervalfornormalflowof(15,27)frames.TheFrameCountReserve(FCR)canbecalculatedbydividingbasalbyhyperaemicTFC.TheFrameCountVelocity(FCV)canbecalculatedbymultiplyingthelengthofthecoronaryarterybytheacquisitionrate(12.5,25,30f/s)anddividingbytheTFC.TIMI心肌灌注分級TIMIMyocardialPerfusionGrade:TMPG0:Failureofdyetoenterthemicrovasculature.TMPG1:Dyeslowlyentersbutfailstoexitthemicrovasculature.TMPG2:Delayedentryandexitofdyefromthemicrovasculature.TMPG3:Normalentryandexitofdyefromthemicrovasculature.Gibsonetal.Circulation2000;101:125-130直接PCI后，雖然心外膜冠狀動脈血流率高，但再灌注未成功BrenerSJetal.CircCVInterv.2012;5:563-9FarkouhMEetal.CircCVInterv.2013;6:216-23心肌灌注分級TIMI血流ST段回落鏡下遠端栓子和無復流

TIMI3級血流

無微血管灌注HenriquesJPSetal.EHJ2002;23:1112-7血栓分級Grade0:Nocine-angiographiccharacteristicsofthrombuspresent.Grade1:Hazy,possiblethrombuspresent.Angiographydemonstratescharacteristicssuchasreducedcontrastdensity,haziness,irregularlesioncontour,orasmoothconvex"meniscus"atthesiteoftotalocclusionsuggestivebutnotdiagnosticofthrombus.Grade2:

Thrombuspresent–smallsize:Definitethrombuswithgreatestdimensionslessthanorequalto1/2vesseldiameter.Grade3:

Thrombuspresent–moderatesize:Definitethrombusbutwithgreatestlineardimensiongreaterthan1/2butlessthan2vesseldiameters.Grade4:Th