冠状动脉造影ABC

直接PCI后，虽然心外膜冠状动脉血流率高，但再灌注未成功
TIMI血流
心肌灌注分级
ST段回落
Brener SJ et al. Circ CV Interv. 2012;5:563-9 Farkouh ME et al. Circ CV Interv. 2013;6:216-23
28 | MDT Confidential UC201204429EE
Estimates of coronary flow using TFG and TFC
Comparisons of PCI vs CABG for revascularization outcomes
1990s •
• • •
Stents era Myocardial blush (心肌染色分级) Brachytherapy, late stent thrombosis, and pharmocotherapy
TMPG 2: Delayed entry and exit of dye from the microvasculature.
TMPG 3: Normal entry and exit of dye from the microvasculature.
Mortality(%)
Relationship between TMPG and mortality
Ryan Circulation 2002, 106:752-756
冠脉造影50余年的历程!
•
1980s
•
•
• •
Thrombolytic era, with the demonstration of spontaneous fibrinolysis during 24 hrs of acute occlusions (心梗24小时内的血栓自溶)
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.
A myocardial bridge occurs when one of the coronary arteries tunnels through the myocardium rather than resting on top of the myocardium
Myocardial bridge in LAD
• 开口: Lesion beginning within 3-5 mm of the origin of a major epicardial artery.
Ostial
Bifurcation
TIMI 血流分级
TIMI Flow grade: • Classification of TFG
– Grade 0, no perfusion – Grade 1, penetration
冠脉造影50余年的历程!
• CA introduced by F. Mason Sones, Jr, MD (首次冠脉造影)
1950s • The first human studies- severity and extent of CAD (首个人体研究)
1960s •
•
•
Earliest natural history studies of proven CAD Dynamic visualization of LV performance (左室造影) Demonstration of prompt and complete revascularization by CABG
TFG 2/1/0 (n=294)
3.5 TFG 3 (n=455)
Mortality(%)
8
7.4
7
6
5
4.7
4.7
4
3
2
1
0.7
0
TMPG 2/1/0 TMPG 3 (n=64) TMPG 2/1/0 TMPG 3 (n=137)
(n=230)
(n=318)
Gibson et al. Circulation 2000; 101:125-130
– This occurs when the descending, inferior, and posterior branches all arise from the RCA.
后降支(PD)
• 均衡型:
– This occurs when only the descending branch arises from the RCA, while the inferior and posterior branches arise from the CX.
The coronary catheter and newer imaging devices (intravascular ultrasound, MRI)
2013
Ryan Circulation 2002, 106:752-756
冠脉造影 股动脉及桡动脉路径
腹股沟韧带
股神经 股总动脉 股静脉
肱动脉
• 左优势:
– This occurs when all three branches arise from the CX.
冠脉起源异常
http://www.radiologyassistant.nl/en/48275120e2ed5
左主干起源 于右冠窦
心肌桥
http://www.radiologyassistant.nl/en/48275120e2ed5
冠心病介入诊疗--ABC
1929年,德国医生Wenner Forssmann在自己身上进行了人类首例 心导管检查术. 他将导管经左肘前静脉,锁骨下静脉,上腔静脉 送入右心房,并拍了医学史上第一张右心导管胸片,从此揭开了 介入心脏病学的序幕.
1959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
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1970s •
• •
• •
Refinement of natural history studies of unoperated CAD patients Discovery of the benefit of CABG vs. Med Rx in subsets of patients Delineation of coronary vasospasm and Prinzmetal’s angina(冠脉痉挛) Significance of coronary pathoanatomy (ulceration, thrombus, dissection, aneurysm, muscle bridge, collateral vessels) Introduction of PTCA and delineation of restenosis (PTCA及再狭窄) First angiographic evidence of clot lysis in a coronary vessel
镜下远端栓子和无复流
TIMI 3 级血流 无微血管灌注
Henriques JPS et al. EHJ 2002;23:1112-7
7
6.2
6
5.1
5
4.4
4
3
2
2
1
0
TMPG 0 (n=434) TMPG 1 (n=79) TMPG 2 (n=46) TMPG 3 (n=203)
Mortality(%)
Relationship between TMPG, TFG and mortality
8 6.8
7 6 5 4 3 2 1 0
冠脉造影提供的信息
• 定量冠脉造影分析
• 冠脉血流
• 心肌灌注
• 其他特性:
– 钙化
– 血栓
– 溃疡
钙化
– 夹层
– 动脉瘤
定量冠脉造影分析(QCA)
• 1近端参考血管直径: • 2. 最小直径: • 3. 远端参考血管直径: • 4. 病变长度: • 直径狭窄:
1
2
3
4
病变特征描述
• 偏心: The plaque is twice as large on one side of the arterial border compared with the other.
尺动脉 桡动脉
穿刺位置 股骨头
解剖学
桡动脉
尺动脉
掌浅弓
Allen 试验
Allen 试验解读
Assement of ulnar arch by oxymetry
Allen’s test is subjective and difficult to interpret
Barbeau score
2 min
Barbeau. G et al; Am Heart J 2004;147:489–93
Barbeau score
NO
Barbeau. G et al; Am Heart J 2004;147:489–93
Amplatz Judkins
冠脉造影 导管
Tiger 导管
JR4 导管
冠脉解剖学
左主干(LM) 左前降支(LAD) 对角支(D1, D2) 间隔支(septal)
Plaque regression studies uncovering the clinical benefits of statin therapy (他汀治疗斑块消褪)
Delineation of the pathogenesis of AMI from studies outlining angiographic progression to MI (AMI的发病机制)
RCA
PLV INF PDA AM
LMS LAD D1
Septal D2
左前降支
Radiographics 2007;27:1569-1582
Marginal branch
右冠状动脉
Conus branch
Marginal branch
Radiographics 2007;27:1569-1582
• 钙化: Readily apparent densities noted within the apparent vascular wall at the site of the stenosis.
• 弥漫: Lesion is ≥20 mm in length.
• 分叉: Atherosclerotic plaque involves the origin of two separate arteries.
Gibson C M et al. Circulation 1999;99:1945-1950
TIMI 心肌灌注分级
TIMI Myocardial Perfusion Grade:
TMPG 0: Failure of dye to enter the microvasculature.
TMPG 1: Dye slowly enters but fails to exit the microvasculature.
without perfusion – Grade 2, partial perfusion – Grade 3, complete
perfusion
TFG0
TFG1
TFG2
TFG3
TIMI 计帧
TIMI Frame Count:
Gibson 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.
回旋支
回旋支 (Cx) 钝缘支 (OM1, OM2)
LAD OM1 CX OM2
回旋支
OM CX
LMS

OM
OM
Radiographics 2007;27:1569-1582
中间支
LMS IM CX
Radiographics 2007;27:1569-1582
冠脉优势型
后侧支(PL)
• 右优势: