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当前位置:首页 > 商业/管理/HR > 项目/工程管理 > IVUS在冠脉介入治疗中的应用
IVUSinClinicalDecisionMaktingImageofIVUSandAngioQuestion•TreatorNotreat?Isitsevere?Isthereanyplaque?•Whereandhowtotreat?Astent?Rotablator?CutingBalloon?Whichsize?•Asacompanyguy,howcanweintroduceourproducts?Agenda•ShouldIstent?‒ScientificevidenceforIVUS‒Determininglesionsignificance•HowshouldIapproach?‒Interventionaldevicesizing‒Implicationsofvesselremodeling•DidIdoitright?‒Expansion‒Apposition‒Edges‒CoverageShouldIstent?HowshouldIstent?DidIdoitright?HowIVUSCanHelpAPracticalApproachtoIVUS-GuidedStentingImaginginClinicalDecisionMakingLesionAssessment•Patient-relatedconsiderations•Acuity•Symptoms•Lesion-relatedconsiderations•Plaquestability(rupture/thrombus)•IschemiaShouldIstent?ReferenceDiameter3.5mmReferenceDiameter3.0-3.5mmReferenceDiameter2.5-3.0mmIVUSMLA(mm2)IVUSMLA(mm2)IVUSMLA(mm2)(%)MLAassociatedwithischemiaisdependentonthevesselsizethatisbeingevaluated(%)(%)Ben-Doretal.Eurointervention.2011Jun;7(2):225-33.MLA(mm2)MLD/StentSize(mm)4.02.255.02.56.02.757.03.0IVUSDeterminantsofLMCAFFR0.75MLAandMLDgivegoodestimationsofsignificanceinLMJastietal.Circulation2004;110:2831-6.ThesafetyandefficacyofBostonScientificstentshasnotbeenestablishedinLMPCI.MLDMLACSNAS%020406080100123452.8mmSensitivity93%Specificity98%Sensitivity90%Specificity88%02040608010012812145.9mm2Sensitivity93%Specificity94%02040608050%Sensitivity86%Specificity80%67%100010203040506070809002040608010020304050607080904610%%%IVUSCriteriafora‘Significant’LMCAStenosisSuggestedcriteriaforsignificantLMCAstenosisLumenMLA6.0mm2(orMLD3.0mm)•CorrelateswithaLMCAFFR0.75•Doesnotdependonfindingadisease-freereferencesegment•Longtermdata(LITROregistry)DeLaTorreHernandezetal.JAmCollCardiol2011;58:351-8.AdaptedfromslidecourtesyofMintz,GS.ThesafetyandefficacyofBostonScientificstentshasnotbeenestablishedinLMPCI.DeterminingLesionSignificanceLumenAreaImagecourtesyDr.GaryMintz.Resultsfromcasestudiesarenotpredictiveofresultsinothercases.Resultsinothercasesmayvary.Uselumenareatoassesslesionsignificance•Areaismeasuredinmm2LumenAreaIllustrationsbyBostonScientificCorporation.1AbizaidA,etal.Circulation.1999Jul20;100(3):256-261.2JastiV,etal.Circulation.2004;110:2831-2836.Measurelumenareaatthetightestpoint–Generally,onemeasurementneeded–Inproximalepicardialvessels•4.0mm2hasbeenpreviouslyconsideredsignificant,butnewerdatasuggeststhevesselsizemattersindeterminingsignificanceoflesionsbyIVUS–Inleftmainvesseltype•6.0mm2isgenerallyconsideredsignificantinanaverage-sizedpatientwithfocaldisease2DeterminingLesionSignificanceMinimumLumenArea(MLA)–IVUSCaseExample:RCACaseExample:RCAIVUSCaseExample:RCAIVUSMeasurementsRed=ProximalReferenceYellow=LesionWhite=DistalReferenceRed=ProximalReferenceYellow=LesionWhite=DistalReferenceCaseExample:RCAIVUSMeasurementsCaseExample:RCAIVUSMeasurementsRed=ProximalReferenceYellow=LesionWhite=DistalReferenceCaseExample:RCAPCICaseExample:RCAPost-PCILesionSignificanceReviewProximalReferenceLesionSiteDistalReferenceLumen%LumenAreaStenosisMinimumLumenArea(MLA)ImagescourtesyDr.GaryMintz.Resultsfromcasestudiesarenotpredictiveofresultsinothercases.Resultsinothercasesmayvary.•Whatinformationdoesthe“proximalreference”and“lesionsite”provide?•Whatinformationdoesthe“lesionsite”provide?LesionSignificanceReviewLeftMainReferencePoint:14.67LeftMainMLA:4.84ImagesbyBostonScientificCorporation.Resultsfromcasestudiesarenotpredictiveofresultsinothercases.Resultsinothercasesmayvary.IC-258502-AAJUL2014D2MLAProximalreferenceLesionLength•Normalvessel–Intermembrance0.5mm•Distalsegment(normal-lookingsegment)–Lesionorstentdistal5mm•Proximalsegment(normal-lookingsegment)–Lesionorstentproximal5mmDistalreferenceImaginginClinicalDecisionMakingPre-interventionIVUS•Lesionsizeandlength•Referencevesselsize•Overallplaqueburden•Unusuallesionmorphology•Calcium•Remodeling•Attenuatedplaque•Spontaneousdissections•PlanningadjunctivestrategiesHowshouldIstent?0%10%20%30%40%-2-1012340%10%20%30%40%-2-101234IVUSlumen-QCA(mm)IVUSmidwall-QCA(mm)IVUSEEM-QCA(mm)0%10%20%30%40%-2-101234ReferenceMeasurements:QCAvs.IVUSIVUSslightlylargerthanQCA(0-1mm)IVUSlargerthanQCA(0-2mm)IVUSlargerthanQCA(1-2mm)Mintz,G.S.,2005,IntracoronaryUltrasound,Taylor&Francis,Oxon,UK,60-65p.•UsingIVUSdiameterdetermination11.Measurelumenatreferencepoint(withintheimageslicewiththelargestlumenandsmallestplaqueburden)2.SizeinterventionaldeviceaccordinglyInterventionalDeviceSizing*IllustrationbyBostonScientificCorporation.*IVUSmeasurementsmaybeusedbythetreatingphysiciansasaguidefordevicesizingdeterminations.1MintzGetal.AmericanCollegeofCardiologyClinicalExpertConsensusDocumentonStandardsforAcquisition,measurementandReportingofIntravascularUltrasound.J.Amer.CollegeofCard.2001:1478-1492.B1proximalB2distal3.5mm3.0mmIC-258502-AAJUL201406.5mm26.0mm5.45.35.05.05.04.34.23.84.02.5•Largestreferencelumen(proxordist)•Midwall•Media-to-media(typicallydiscounted)IncreasinglyaggressiveImagescourtesyofGaryMintz,MD.Resultsfromcasestudiesarenotpredictiveofresultsinothercases.Resultsinothercasesmayvary.•UsingIVUSlengthdetermination3.5mm3.0mmInterventionalDe
本文标题:IVUS在冠脉介入治疗中的应用
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