血管内超声基本知识 浙江大学医学院附属第二医院 心内科 项美香

内容 IVUS基础 IVUS对冠脉病变的诊断作用 IVUS对冠脉介入治疗的指导作用 什么是VH？

什么是IVUS？ IntraVasocular UltraSound A detection device receives sound waves

通过患者接口模块（PIM），主机和超声导管相连接

超声导管 机械旋转型和电子相控阵型 Rotating Element Drive Shaft Multi-element Array To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

工作原理 The IVUS Transducer in the catheter tip emits High-frequency sound waves (MHz) through blood (conductive) Transducer: Device to convert electrical energy into sound energy and vice versa

工作原理 The system creates a Cross-sectional image based on the intensity of the returned Waves. electrical imput sound Sound reflected electrical output After reflection from tissue, these same sound waves return to the crystal (transducer) that produces an electrical impulse that is then converted into the image.

工作原理 Sending, Receiving, Processing Sound Waves to create a Cross-sectional picture of an artery Sending, Receiving, Processing Sound Waves to create a Cross-sectional picture of an artery High frequency sound waves echo off vessel walls and are sent back to system High frequency sound waves echo off vessel walls and are sent back to system System electronics process the signal System electronics process the signal

IVUS与冠状动脉造影 CAG: 血管的轮廓 局部的病变 偏心性斑块 IVUS: 血管壁和血管腔的结构 斑块的负荷 斑块的组成和特征

IVUS 血栓 夹层 壁内血肿 心肌桥 模糊病变

This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

斑块的性质：钙化斑块 Bright echoes (brighter than the adventitia) Obstructs the penetration of ultrasound (acoustic shadowing) only the leading edge is detected and thickness cannot be determined. Results in reverberations - the oscillation of ultrasound between transducer and calcium causing repeating ‘arcs’ This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

分型：0-IV Calcium is classified by its location within the plaque 分类：浅层和深层钙化 分型：0-IV 80° Superficial Deep Calcium is classified by its location within the plaque Superficial calcium is closer to the lumen than to the adventitia Deep calcium is closer to the adventitia than to the lumen This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

纤维化斑块 As bright or brighter than the adventitia (hyperechoic) Majority of atherosclerotic lesions are fibrotic Very dense, fibrous plaques may cause so much acoustic shadowing that they could be misclassified as calcified This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

软斑块 Not as bright as the adventitia (hypoechoic) “Soft” refers to the low echogenicity, generally due to high lipid content in a mostly cellular lesion. Reduced echodensity may also be due to: necrotic zone within plaque intramural hemorrhage thrombus This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

易损斑块--VP Lipid Core Fibrous Cap This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) Fibrous Cap Lipid Core

混合性斑块 This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

IVUS在冠脉病变诊断中的应用 造影的临界病变 左主干病变 分叉病变 模糊病变 支架内再狭窄

Takagi, et al. Circulation 1999;100:250-5 临界病变-LAD Intermediate stenosis assessment: If in Proximal LAD, CC or RCA, the stenosis MLA ≤ 4 mm2 then is cause isquemia; and must be treated Takagi, et al. Circulation 1999;100:250-5

LM病变 Intermediate Main Left stenosis assessment: If Main Left MLA ≤ 6 mm2 cause isquemia and must be treated Abizaid, et al. J Am Coll Cardiol 1999;34:707-715 IVUS assess significance of Main Left lesions, where angio fails

分叉病变 Because the precise view of vessel branches access and plaque placement, IVUS guidance anticipates risk of undergrowth preservation IVUS allows visualization of Plaque, Definition of plaque characteristic and Prevents plaque shift

Peri-Stent Haziness: Plaque Burden Two Overlapping Stents Hazy Segment

Peri-Stent Haziness: Double Lumen

Peri-Stent Haziness: Calcification 南方会2008

Peri-Stent Injury: Plaque Tear Ultrasound Site Stent

IVUS reveals stent underexpansion in ISR 支架内再狭窄 Because the vessel and plaque and stents became visible, IVUS guidance clarify substrate in failure or previous PCI, and frequently discover under expanded stents IVUS reveals stent underexpansion in ISR

In-Stent Restenosis In-stent intimal hyperplasia (IH) often appears with a very low echogenicity Could be less echogenic than the blood speckle Appropriate system settings are critical to visualize IH (do not “black out” center) This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle)

Non-stented artery 支架植入中指导作用： 最小管腔CSA EEM Guidewires IVUS catheter Plaque+media Lumen This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 支架植入中指导作用： 最小管腔CSA

Proximal Reference Lesion Site Distal Reference EEM Lumen P+M Min P+M Thickness This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) Max P+M Thickness Ca++

Average Reference EEM CSA = 16.9 Average Reference Lumen CSA = 9.3 Proximal Reference Lesion Site Distal Reference 3mm 12mm EEM CSA = 20.4 Lumen CSA = 9.7 Max lumen diam = 3.7 MLD = 3.1 P+M CSA = 10.7 Eccentricity = 1.0/0.3 Plaque burden = 0.52 Arc of Ca = 60 EEM CSA = 21.6 Lumen CSA = 4.5 Max lumen diam = 32.8 MLD = 2.3 P+M CSA = 17.1 Eccentricity = 3.0/0.1 Plaque burden = 0.79 EEM CSA = 13.3 Lumen CSA = 8.9 Max lumen diam = 3.6 MLD = 3.0 P+M CSA = 4.4 Eccentricity = 0.6/0.2 Plaque burden = 0.33 This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) Average Reference EEM CSA = 16.9 Remodeling Index = 1.3 Average Reference Lumen CSA = 9.3 Area Stenosis = 52%

Stent sizing using IVUS 6mm 5.5mm Proximal Lesion Distal This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) Max LD = 3.3 mm Max LD = 3.5 mm Reference segment disease provides a cushion for oversizing

Proximal 3mm 12mm EEM CSA = 21.0mm2 Lumen CSA = 9.5mm2 3mm 12mm EEM CSA = 21.0mm2 Lumen CSA = 9.5mm2 P+M CSA = 11.5mm2 EEM CSA = 23.5mm2 Lumen CSA = 5.5mm2 P+M CSA = 18.0mm2 EEM CSA = 13.7mm2 Lumen CSA = 9.3mm2 P+M CSA = 4.4mm2

Stented Artery 支架植入后的评价作用 ： 支架帖壁（良好）、扩张（充分）、展开（均称）和病变覆盖（完全） EEM Stent Lumen Stent Guidewire IVUS catheter Plaque+media Intimal hyperplasia This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 支架植入后的评价作用 ： 支架帖壁（良好）、扩张（充分）、展开（均称）和病变覆盖（完全）

Virtual HistologyTM Volcano IVUS PC with 500 MHz and reconstruction software Eliminate the S-VHS VCR

Plaque Composition Dense Calcium – Focal areas of dense calcium – Shown in WHITE on VH Necrotic Core - Localized area of loss of matrix, presence of lipid (typically with micro-calcifications) Shown in RED on VH Fibrous – Densely packed collagen fibers with no evidence of intra-fiber lipid accumulation – Shown in DARK GREEN on VH Fibro-Fatty – Loosely packed collagen fibers with regions of fatty deposits present – Shown in YELLOW on VH

Virtual HistologyTM Volcano FIBROTIC FIBRO-LIPID CALCIFIC LIPID CORE MEDIA Legend Classification

FIBROTIC FIBRO-LIPIDIC LIPIDIC-CORE CALCIFIC Virtual HistologyTM Ex-Vivo Validation FIBROTIC FIBRO-LIPIDIC LIPIDIC-CORE CALCIFIC

Comparison Between VH and Histology Diagnostic accuracy Nair et al. Circulation 2002 The plaque component values were assigned color codes and the tissue maps were reconstructed in the software. Right panel shows the diagnostic accuracy of virtual histology plaque component, which was reported by Nair et al in Circulation 2002. In this report, the predictive accuracy, sensitivity, and specificity were high between virtual histology and real histology.

Plaque Classification - I Adaptive Intimal Thickening Plaque comprised of nearly all fibrous tissue. (<5% of fibrofatty, calcification and/or NC plaque). (Generally not viewed by Dr. Virmani to be acutely dangerous) Pathological Intimal Thickening – Mainly mixture of fibrous, fibrofatty (>5%), and necrotic core and some calcified tissue <5%.

Plaque Classification - II “Fibro-Atheroma” – Fibrotic cap and significant Necrotic Core (confluent NC >5% of total plaque volume) in fibrotic and/or fibrofatty tissue It is very likely be that the most important goal is to differentiate the FibroAtheroma plaque types from the other three plaque types during assessments of high risk lesions for rupture.

Fibro-Atheroma For purposes of risk-assessment, Fibro-Atheroma can be further differentiated into sub-groups: 4.1 “Fibro-Atheroma without Dense Calcium” – Fibro-Atheroma without presence of Dense Calcium. Note that here Necrotic Core is also not displayed as “on” or near the lumen on VH. 4.2 “Fibro-Atheroma with Dense Calcium” – Fibro-Atheroma with Dense Calcium present in plaque (generally viewed as being more dangerous than FA without DC). Note that here Necrotic Core is not displayed as “on” or near the lumen on VH.

Fibro Atheroma with Fibrous Cap P Margolis, Volcano Corp.

Fibro Atheromas without evidence of thick fibrous cap P Margolis, Volcano Corp.

Fibro-Calcific Plaque Plaque Classification - III Fibro-Calcific Plaque “Fibro-Calcific” – Mainly fibrous plaques with Dense Calcium (>5% of plaque volume). Presence of Necrotic Core <5% of plaque volume. Single or multiple layers of calcium with or without severe narrowing (deep or superficial sheet of calcium). Sign of plaque stabilization.

Thin-Cap FibroAtheroma (TICFA) “Thin Cap Fibro-Atheroma (TICFA)” or “Vulnerable Plaque” -- Necrotic Core is significant (>10% of total plaque volume) and located at or near the lumen. Further sub-classification based on presence of luminal narrowing may yield further prognostic value in assessing TICFA risk. “TICFA with significant narrowing” (significant narrowing defined as ≥50% reduction in Cross Sectional Area on IVUS or DS≥25% on angiogram) - Dr. Virmani’s data suggests that TICFA with significant narrowing represents the highest risk of all plaques. “TICFA without significant narrowing” (<50% area reduction on IVUS or <25% DS on angiogram - Dr. Virmani’s data suggests that TICFA without significant narrowing is at a considerably lower risk.

Thin Cap Fibro Atheroma (TCFA) “Thin Cap Fibro-Atheroma (TICFA)” or “Vulnerable Plaque” -- Necrotic Core is significant (>10% of total plaque volume) and located on or near the lumen at VH. Based on the presence or absence of Ca, the length of the lesion by NC, or signs of previous ruptures, TCFA can be further sub-classified for the purpose of risk assessment (Vulnerability Index = VI) <5% calcium >5% calcium multiple layers VI 1 VI 2 VI 3 Still further sub-classification based on presence of luminal narrowing and other risk factors may yield further prognostic value in assessing TICFA risk. “High Risk TCFA” (VI 4) Confluent NC>20% No evidence of fibrotic cap Calcium >5% Remodeling index >1.05 >50% cross sectional area luminal narrowing by IVUS “TICFA without significant narrowing” - CSA reduction of less than 50% on IVUS and/or less than 25% narrowing on angiogram. (Dr. Virmani’s data suggests that TICFA without significant narrowing suggests a considerably lower risk TICFA)

谢谢！