血管内超声图像识图培训---(波士顿科学技术)

1IVUS读图培训波士顿科学公司2BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally目录•IVUS临床意义•IVUS图像的解读•IVUS图像测量•IVUS在PCI术中使用过程3BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally目录•IVUS的临床意义—WHYIVUS•IVUS图像的解读•IVUS图像测量•IVUS在PCI术中使用过程4BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally冠状动脉造影-冠脉介入诊断的金标准?5BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally冠脉造影的局限性局限性病变狭窄50%弥漫性病变狭窄50%6BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally斑块形态及投影角度ABCCrossSectionRAOViewLAOView7BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally冠脉造影不能显示的病变对884条冠状动脉进行分析发现，在所谓冠脉造影正常的参考节段，斑块负荷为5113%MintzGS,etal.Atherosclerosisinangiographicallynormalcoronaryarteryreferencesegments.JAmCollCardiol1995;25:1479-14858BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternallyIVUSvs.造影介导的DES置入术IVUS介导造影介导p30天MACE2.8%5.2%0.01支架内血栓0.5%1.4%0.045TLR0.7%1.7%0.0451年MACE14.5%16.2%0.3肯定的支架内血栓0.7%2.0%0.014可能的支架内血栓4.0%5.8%0.08TLR5.1%7.2%0.06肯定的极晚期支架内血栓0.2%0.7%0.3(Royetal.EurHeartJ2008;29:1851-7)9BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally血管内超声的临床应用术前•评估病变的严重性，是否需要进行干预•靶病变区域形态学评估,判断使用球囊、支架或旋磨•寻找病变的近端及远端参考，以帮助确定支架的长度•测量血管大小从而帮助选择合适直径的支架术中•支架贴壁评估•优化支架扩张•评估支架“地理缺失”(GeographicMiss)•边缘夹层判断术后•靶病变血管重建(TLR)和靶血管失败(TVF)评估•死亡和心梗评估•血栓形成评估10BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally目录•IVUS的临床意义---WHYIVUS•IVUS图像的解读•IVUS图像测量•IVUS在PCI术中使用过程11BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally•基本斑块特性识别与读图步骤12BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally123血管在超声下的影像•1:外膜是由胶原蛋白组成，超声反射信号强烈（显示为白色）•2:中膜是由平滑肌细胞组成，无超声回波信号（显示为黑色）•3:内膜致密，介于中膜和血流之间，显示为白色113BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally正常血管IVUS图像：致密回声的内膜，低回声中膜和致密回声的外膜正常管腔结构14BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally正常动脉IVUS截面上有什么1.血管外膜层：回波密集：弹性蛋白和胶原蛋白：纤维化2.无回波层：血管中膜层：平滑肌细胞3.回波密集的血管内膜层4.管腔：血液5.衰荡区：“光晕”6.盲区：导管654321正常IVUS图像基本判读波士顿科学公司机密——仅供内部使用。严禁对外复制、展示或分发。15BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally正常IVUS图像基本判读1正常动脉3层结构3211.外膜2.中膜3.内膜16BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally正常IVUS图像基本判读2正常动脉BostonScientificAtlantis®40Mhz3层结构1.外膜2.中膜3.内膜17BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternallyNormal正常IVUS图像基本判读318BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternallyDiseased病变血管影像19BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally血管内超声的斑块分类钙化斑块致密回声斑块（”纤维”)低回声斑块（“软”）20BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally软斑块•斑块位于管腔/内膜与外弹力膜（EEL）之间•声影亮度，比外膜暗•超声显示为低回声区域或无回声区域•斑块不均一21BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally纤维化斑块（低脂质）•斑块位于管腔/内膜与外弹力膜（EEL）之间•声影亮度接近外膜•回声信号介于软斑块和钙化斑块之间•大部分斑块不均一22BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally钙化•高回声，呈现高亮影像（比外膜高亮）•阻挡超声波的辐射（回声声影缺失）•只能探测到钙化的浅层区域，无法辨明厚度。22Behindcalcium:AcousticShadow23BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally混合斑块斑块成分有多种回声，难于确定主要为哪种类型，则定义为混合斑块。坏死核心纤维帽钙化病变24BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally超声影像识图1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜边5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支25BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜边5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-126BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜边5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-227BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜边5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-328BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-429BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-530BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-631BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally1.导管2.导丝伪影3.血池闪烁斑点(影像中比静止图片更明显)4.内膜5.管腔6.中膜边界/外弹性膜7.动脉粥样化8.外膜9.边支超声影像识图-732BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExternally•典型病变辨识33BostonScientificConfidential--ForInternalUseOnly.DoNotCopy,DisplayorDistributeExt