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1、造影结果的判读及病变类型的分析黄文晖广东省人民医院广东省心血管病研究所从造影片我们要看什么？如何体位的片中判断正常的冠脉血管？如何判断病变的血管？常用的一些分类通过不同的病变类型如何考虑介入治疗的难度？从造影片我们要看什么？血管的情况肺野的情况心包情况现场还要注意压力的变化正常冠状动脉RCABasic AnatomyOrigin right aortic sinus(lower origin than LCA)Course Down right AV groove toward crux of the heart, gives off PDA(85%) from which septals a
2、rise, continues in LAV groove giving off posterior LV branches(posterolaterals). PDA may originate more proximally, bifurcate early or be small with part of “its territory” supplied by an acute marginal branch.RCAOther BranchesConus Artery(圆锥支) usually very proximal; courses anteriorly and upward ov
3、er the RV outflow tract toward the LAD. May be an important Source of collaterals.SA Nodal Artery(窦房结动脉) (60%) usually 2nd branch of RCA-courses obliquely backward through uper portion of aterial septum and anteromedial wall of the RA-supplies SA node,usually RA and sometimes LA RCAOther BranchesPDA
4、(后降支) Supplies inferior wall, ventricular septum, posteromedial papillary muscle.AV Nodal Artery (房室结支) Arises at or near crux; supplies AV node.Right ventricular(Acute marginal Branches锐缘支) Arise from mid RCA; Supply anterior RV; may be a collateral source.RCAOptimal View(s)LAO(30) Cranial(30) part
5、icularly for distal bifurcation(AP cranial may be better).RAO main shaft; cranial enhances distal vessels and very proximal; caudal may help with shepherds crook.Lateral bifurcations with RV branches-distal bifurcation, particularly with cranial.RCA1.圆锥支2.窦房结支3.右室支4.锐缘支5.后降支6.后侧支LCALMOptimal Views L
6、AO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUSLADCourse down the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apexLCABranches septals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus
7、( courses like 1st diagonal).LAD supplies anterolateral, apex and septum; 45%-55% of left ventricle.LCXBranches obtuse marginal, posterolaterals-supply posterolateral LV, anterolteral papillary muscles. SA node artery 38%Supplies 15%-25% of LV, unless dominant(supplies 40-50% of LV).AP Caudal view o
8、f LCAAP CranialLAO Cranial View LAO Caudal ViewAHA/ACC冠脉病变分类A型病变散在病变(长度10mm)向心型狭窄容易插管到病灶部位各节段间成角450 血管表面较平滑无钙化或很轻度钙化不是管腔完全闭塞狭窄部位不在血管开口处无重要分支狭窄管腔内无血栓B型病变病变成管状(10-20mm).偏心型狭窄近端节段中度弯曲各节段间成角450 -900 血管表面不光滑中度或重度钙化管腔完全闭塞2cm)近端节段过度弯曲节段间成角900管腔完全闭塞3个月不能防止主要的分支受损移植静脉退行性变易碎破TIMI 血流分级0级: 无灌注,梗塞相关血管完全闭塞,无造 影剂通
9、过狭窄部位.1级: 少量造影剂通过病变,但不能使远端动脉血管床充分显影2级:血流3个心动周期才能使病变远端的动脉血管床充分显影(30桢/秒)3级:完全灌注, 3个心动周期远端的动脉血管床充分显影(30桢/秒)TIMI心肌灌注分级(TMPG)0级:心肌无明显组织灌注,罪犯血管区域无毛玻璃样改变或心肌显影,提示组织水平灌注低下。1级：造影剂缓慢灌注心肌，但不能从微血管排空，毛玻璃样改变或罪犯血管区域心肌显影不能从微血管清除，心肌显影在开始下一个造影序列（间隔30秒）时仍然存在。TIMI心肌灌注分级(TMPG)2级：造影剂进出微血管均延迟，罪犯血管区域毛玻璃样改变或心肌显影在排空末期持续存在。（3个心动周期持续显影）3级：造影剂正常进出微血管，毛玻璃样改变或犯罪血管心肌显影清除正常，于排空末期消失或轻微/中度持续（ 3个心动周期） 谢 谢!
