1. 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

2. 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？

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

4. 通过患者接口模块（PIM），主机和超声导管相连接

5. 超声导管 机械旋转型和电子相控阵型 Rotating Element Drive Shaft Multi-element Array
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6. 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

7. 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.

8. 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

9. 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

10. IVUS 血栓 夹层
壁内血肿
心肌桥
模糊病变

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12. 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’
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13. 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
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14. 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
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15. 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
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16. 易损斑块--VP Lipid Core Fibrous Cap This is the Bulleted List slide.
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Fibrous Cap
Lipid Core

17. 混合性斑块 This is the Bulleted List slide.
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18. 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

19. 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

20. 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:
IVUS assess significance of Main Left lesions, where angio fails

21. 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

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

23. Peri-Stent Haziness: Double Lumen

24. Peri-Stent Haziness: Calcification
南方会2008

25. Peri-Stent Injury: Plaque Tear
Ultrasound
Site
Stent

26. 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

27. 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)
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28. Non-stented artery 支架植入中指导作用： 最小管腔CSA EEM Guidewires IVUS catheter
Plaque+media
Lumen
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支架植入中指导作用：
最小管腔CSA

29. Proximal Reference Lesion Site Distal Reference
EEM
Lumen
P+M
Min P+M Thickness
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Max P+M Thickness
Ca++

30. 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
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Average Reference EEM CSA = 16.9
Remodeling Index = 1.3
Average Reference Lumen CSA = 9.3
Area Stenosis = 52%

31. Stent sizing using IVUS
6mm
5.5mm
Proximal
Lesion
Distal
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Max LD = mm
Max LD = 3.5 mm
Reference segment disease provides a cushion for oversizing

32. 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 = mm2

33. 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
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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）

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

35. 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

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

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

38. 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 In this report, the predictive accuracy, sensitivity, and specificity were high between virtual histology and real histology.

39. 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%.

40. 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.

41. 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.

42. Fibro Atheroma with Fibrous Cap
P Margolis, Volcano Corp.

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

44. 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.

45. 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.

46. 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 VI 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)

47. 谢谢！