冠心病介入診療--ABC整理課件1929年,德國醫生WennerForssmann在自己身上進行了人類首例心導管檢查術.他將導管經左肘前靜脈,鎖骨下靜脈,上腔靜脈送入右心房,并拍了醫學史上第一張右心導管胸片,從此揭開了介入心臟病學的序幕.整理課件1959年MasonSones

利用特制的尖端呈弧形的造影導管,經肱動脈送入主動脈根部進行主動脈造影,無意中將造影劑直接注入右冠狀動脈內使其清晰顯影,這一偶然事件開創了冠脈介入診斷技術的新紀元整理課件冠脈造影50余年的歷程!CAintroducedbyF.MasonSones,Jr,MD(首次冠脈造影)

Thefirsthumanstudies-severityandextentofCAD(首個人體研究)EarliestnaturalhistorystudiesofprovenCAD????DynamicvisualizationofLVperformance(左室造影)

DemonstrationofpromptandcompleterevascularizationbyCABGRefinementofnaturalhistorystudiesofunoperatedCADpatientsDiscoveryofthebenefitofCABGvs.MedRxinsubsetsofpatientsDelineationofcoronaryvasospasmandPrinzmetal’sangina(冠脈痙攣)Significanceofcoronarypathoanatomy(ulceration,thrombus,dissection,aneurysm,musclebridge,collateralvessels)IntroductionofPTCAanddelineationofrestenosis(PTCA及再狹窄)Firstangiographicevidenceofclotlysisinacoronaryvessel1950s1960s1970sRyanCirculation2002,106:752-756整理課件冠脈造影50余年的歷程!Thrombolyticera,withthedemonstrationofspontaneousfibrinolysisduring24hrsofacuteocclusions(心梗24小時內的血栓自溶)Plaqueregressionstudiesuncoveringtheclinicalbenefitsofstatintherapy(他汀治療斑塊消褪)DelineationofthepathogenesisofAMIfromstudiesoutliningangiographicprogressiontoMI(AMI的發病機制)EstimatesofcoronaryflowusingTFGandTFCComparisonsofPCIvsCABGforrevascularizationoutcomesStentseraMyocardialblush(心肌染色分級)Brachytherapy,latestentthrombosis,andpharmocotherapyThecoronarycatheterandnewerimagingdevices(intravascularultrasound,MRI)1980s1990sRyanCirculation2002,106:752-7562013整理課件冠脈造影

股動脈及橈動脈路徑股神經股總動脈股靜脈穿刺位置股骨頭腹股溝韌帶尺動脈橈動脈肱動脈整理課件解剖學橈動脈掌淺弓尺動脈整理課件Allen試驗整理課件Allen試驗解讀整理課件AssementofulnararchbyoxymetryAllen’stestissubjectiveanddifficulttointerpretBarbeauscoreBarbeau.Getal;AmHeartJ2004;147:489–932min整理課件Barbeau.Getal;AmHeartJ2004;147:489–93NOBarbeauscore整理課件冠脈造影

導管JudkinsAmplatzTiger導管JR4導管整理課件冠脈解剖學左主干(LM)左前降支(LAD)對角支(D1,D2)間隔支(septal)LADD1SeptalD2LMSRCAPLVINFPDAAM整理課件左前降支Radiographics2007;27:1569-1582整理課件Radiographics2007;27:1569-1582右冠狀動脈MarginalbranchConusbranchMarginalbranch整理課件回旋支回旋支(Cx)鈍緣支(OM1,OM2)OM1CXOM2LAD整理課件Radiographics2007;27:1569-1582回旋支OMOMLMSCXCXOM整理課件Radiographics2007;27:1569-1582中間支IMCXLMS整理課件右優勢:

Thisoccurswhenthedescending,inferior,andposteriorbranchesallarisefromtheRCA.均衡型:

ThisoccurswhenonlythedescendingbrancharisesfromtheRCA,whiletheinferiorandposteriorbranchesarisefromtheCX.左優勢:

ThisoccurswhenallthreebranchesarisefromtheCX.冠脈優勢型后側支(PL)后降支(PD)整理課件冠脈起源異常左主干起源于右冠竇http://www.radiologyassistant.nl/en/48275120e2ed5整理課件心肌橋MyocardialbridgeinLADhttp://www.radiologyassistant.nl/en/48275120e2ed5Amyocardialbridgeoccurswhenoneofthecoronaryarteriestunnelsthroughthemyocardiumratherthanrestingontopofthemyocardium整理課件冠脈造影提供的信息定量冠脈造影分析冠脈血流心肌灌注其他特性:鈣化血栓潰瘍夾層動脈瘤鈣化整理課件定量冠脈造影分析(QCA)1近端參考血管直徑:2.最小直徑:3.遠端參考血管直徑:4.病變長度:直徑狹窄:1234整理課件病變特征描述偏心:Theplaqueistwiceaslargeononesideofthearterialbordercomparedwiththeother.鈣化:Readilyapparentdensitiesnotedwithintheapparentvascularwallatthesiteofthestenosis.彌漫:Lesionis≥20mminlength.分叉:Atheroscleroticplaqueinvolvestheoriginoftwoseparatearteries.開口:

Lesionbeginningwithin3-5mmoftheoriginofamajorepicardialartery.BifurcationOstial整理課件TIMI血流分級TIMIFlowgrade:ClassificationofTFGGrade0,noperfusionGrade1,penetrationwithoutperfusionGrade2,partialperfusionGrade3,completeperfusionTFG0TFG1TFG2TFG3整理課件TIMI計幀TIMIFrameCount:GibsonCMetal.Circulation1999;99:1945-1950GibsonetalfoundameancorrectedTFC(cTFC)fornormalcoronaryarteriesof213.1frames,yieldinga95%confidenceintervalfornormalflowof(15,27)frames.TheFrameCountReserve(FCR)canbecalculatedbydividingbasalbyhyperaemicTFC.TheFrameCountVelocity(FCV)canbecalculatedbymultiplyingthelengthofthecoronaryarterybytheacquisitionrate(12.5,25,30f/s)anddividingbytheTFC.整理課件TIMI心肌灌注分級TIMIMyocardialPerfusionGrade:TMPG0:Failureofdyetoenterthemicrovasculature.TMPG1:Dyeslowlyentersbutfailstoexitthemicrovasculature.TMPG2:Delayedentryandexitofdyefromthemicrovasculature.TMPG3:Normalentryandexitofdyefromthemicrovasculature.Gibsonetal.Circulation2000;101:125-130整理課件直接PCI后，雖然心外膜冠狀動脈血流率高，但再灌注未成功BrenerSJetal.CircCVInterv.2012;5:563-9FarkouhMEetal.CircCVInterv.2013;6:216-23心肌灌注分級TIMI血流ST段回落鏡下遠端栓子和無復流

TIMI3級血流

無微血管灌注HenriquesJPSetal.EHJ2002;23:1112-7血栓分級Grade0:Nocine-angiographiccharacteristicsofthrombuspresent.Grade1:Hazy,possiblethrombuspresent.Angiographydemonstratescharacteristicssuchasreducedcontrastdensity,haziness,irregularlesioncontour,orasmoothconvex"meniscus"atthesiteoftotalocclusionsuggestivebutnotdiagnosticofthrombus.Grade2:

Thrombuspresent–smallsize:Definitethrombuswithgreatestdimensionslessthanorequalto1/2vesseldiameter.Grade3:

Thrombuspresent–moderatesize:Definitethrombusbutwithgreatestlineardimensiongreaterthan1/2butlessthan2vesseldiameters.Grade4:Thrombuspresent–largesize:AsinGrade3butwiththelargestdimensiongreaterthanorequalto2vesseldiameters.Grade5:Recenttotalocclusion,caninvolvesomecollateralizationbutusuallydoesnotinvolveextensivecollateralization,tendstohavea“beak”shapeandahazyedgeorappearanceofdistinctthrombus.Grade6:Chronictotalocclusion,usuallyinvolvingextensivecollateralization,tendstohavedistinct,bluntcutoff/edgeandwillgenerallyclotuptothenearestproximalsidebranch.GibsonCMetal.Circulation.2001;103:2550-2554Grade5thrombusGrade4thrombus整理課件動脈瘤Alocalizedarterialwidening(dilatation)thatusuallymanifestsitselfasabulge.Itspresencemayleadtoweakeningofthewallandeventualrupture.Grade0:

None–noectasiapresent.Grade1:

Ectasia–visualassessmentofectasia>1&<1.5timesthenormalarterydiameterlocatedanywhereintheculpritartery.Grade2:

Aneurysm–visualassessmentofananeurysm>1.5timesthenormalarterydiameterlocatedanywhereintheculpritartery.整理課件病變復雜程度AHATaskForceDefinitionasmodifiedbyEllisetal:TypeA:<10mm,discrete,concentricreadilyaccessible,<45degreeanglesmoothcontour,littleornocalcification,lessthantotallyoccluded,notostial,nomajorsidebranchinvolvement,absenceofthrombus.TypeB1:Oneofthefollowingcharacteristics:TypeB2:Twoormoreofthefollowingcharacteristics:10-20mm,eccentric,moderatetortuosityofproximalsegment,irregularcontour,presenceofanythrombusgrade,moderateorheavycalcification,totalocclusion<3monthsold,ostiallesionorbifurcationlesion.TypeC:≥20mmdiffuse,excessivetortuosityofproximalsegment,totalocclusion>3monthsoldand/orbridgingcollaterals,

inabilitytoprotectmajorsidebranches,ordegeneratedveingraftwithfriablelesions. 整理課件分叉病變:Medina分型1,1,1整理課件夾層分級

Anintraluminalfillingdefectorflapassociatedwithahazy,ground-glassappearance.Thiscategoryissub-classifiedusingtheNHLBIsystemforgradingdissectiontypes:TypeA:Radiolucentareaswithinthecoronarylumenduringcontrastinjection,withminimalornopersistenceofcontrastafterdyehascleared.TypeB:Paralleltractsordoublelumenseparatedbyaradiolucentareaduringcontrastinjection,withminimalornopersistenceafterdyehascleared.TypeC:Contrastoutsidethecoronarylumen,withpersistenceofcontrastintheareaafterdyehascleared.TypeD:Spiralluminalfillingdefectsfrequentlywithextensivecontraststainingofthevessel.TypeE:Newpersistentfillingdefectsthatmaybecausedbythrombus.TypeF:ThesearenonA–Edissectiontypesthatleadtoimpairedflowortotalocclusionofthecoronaryartery.Dissection-TypeDDissectionflappostPOBAinaheavilycalcifiedlesion-TypeC整理課件其他穿孔:

Presenceofextra-luminalcontrastthatdevelops duringtheprocedure.分支丟失:

ThedevelopmentofTIMIgrade0or1flowinasidebranchthatwas>1.5mmindiameterpriortotheprocedureandwasinitiallypatentwithTIMIgrade2or3flow.手術成果:

Completesuccess:Ifthepost-procedurevisualresidualstenosisis<50%withnodecrementinflow.Partialsuccess:Ifthereiseithera>50%residualstenosisbyvisualassessmentorifTIMIGrade2Flowisattained(thisincludesTFG2.5).Failure:Ifthereisapersistenttotalocclusion,ifthelesioncannotbecrossed,orifthereispersistentabruptclosure.PerforationPerforationPrePost整理課件其他遠端栓塞:TheappearanceofanabruptcutoffinthedistalvesselfollowingPTCA.無復流:Markedlydelayedflowdownthearterywithminimalresidualstenosis.整理課件側枝循環Partial:

Minimalcollateralspresent.Evidenceofminimaltopartialfillingoftherecipientbranchepicardialarteries/infarctregion.Complete:

Well-developedcollaterals.Evidenceofcollateralcirculationwi