造影結(jié)果的判讀及病變類型的分析黃文暉廣東省人民醫(yī)院廣東省心血管病研究所從造影片我們要看什么？如何體位的片中判斷正常的冠脈血管？如何判斷病變的血管？常用的一些分類通過不同的病變類型如何考慮介入治療的難度？從造影片我們要看什么？血管的情況肺野的情況心包情況現(xiàn)場還要注意壓力的變化正常冠狀動脈RCABasicAnatomyOriginrightaorticsinus(loweroriginthanLCA)CourseDownrightAVgroovetowardcruxoftheheart,givesoffPDA(85%)fromwhichseptalsarise,continuesinLAVgroovegivingoffposteriorLVbranches(posterolaterals).PDAmayoriginatemoreproximally,bifurcateearlyorbesmallwithpartof“itsterritory〞suppliedbyanacutemarginalbranch.RCAOtherBranchesConusArtery(圓錐支)

usuallyveryproximal;coursesanteriorlyandupwardovertheRVoutflowtracttowardtheLAD.MaybeanimportantSourceofcollaterals.SANodalArtery(竇房結(jié)動脈)(~60%)usually2ndbranchofRCA-coursesobliquelybackwardthroughuperportionofaterialseptumandanteromedialwalloftheRA-suppliesSAnode,usuallyRAandsometimesLA

RCAOtherBranchesPDA(后降支)

Suppliesinferiorwall,ventricularseptum,posteromedialpapillarymuscle.AVNodalArtery(房室結(jié)支)

Arisesatornearcrux;suppliesAVnode.Rightventricular(AcutemarginalBranches銳緣支)

ArisefrommidRCA;SupplyanteriorRV;maybeacollateralsource.RCAOptimalView(s)LAO(30)Cranial(30)particularlyfordistalbifurcation(APcranialmaybebetter).RAOmainshaft;cranialenhancesdistalvesselsandveryproximal;caudalmayhelpwithshepherd’scrook.LateralbifurcationswithRVbranches-distalbifurcation,particularlywithcranial.RCA圓錐支竇房結(jié)支右室支銳緣支后降支后側(cè)支LCALMOptimalViewsLAOcaudalandcranial;AP-caudal,cranialorflat.Limitviews.MayneedIVUSLADCourse

downtheanteriorinterventriculargroove-usuallyreachesapex.In22%ofcasesdoesnotreachapexLCABranches

septalsanddiagonals-supplylateralwallofLV,anterolateralpapillarymuscle;37%havemedianramus(courseslike1stdiagonal).LAD

suppliesanterolateral,apexandseptum;~45%-55%ofleftventricle.LCXBranchesobtusemarginal,posterolaterals-supplyposterolateralLV,anterolteralpapillarymuscles.SAnodeartery38%Supplies15%-25%ofLV,unlessdominant(supplies40-50%ofLV).APCaudalviewofLCAAPCranialLAOCranialViewLAOCaudalViewAHA/ACC冠脈病變分類A型病變散在病變(長度<10mm)向心型狹窄容易插管到病灶部位各節(jié)段間成角<450血管外表較平滑無鈣化或很輕度鈣化不是管腔完全閉塞狹窄部位不在血管開口處無重要分支狹窄管腔內(nèi)無血栓B型病變病變成管狀(10-20mm).偏心型狹窄近端節(jié)段中度彎曲各節(jié)段間成角450-900血管外表不光滑中度或重度鈣化管腔完全閉塞<3個月狹窄部位在開口處血管分叉處需要2根導(dǎo)引鋼絲管腔內(nèi)有血栓C型病變彌漫性病變(>2cm)近端節(jié)段過度彎曲節(jié)段間成角>900管腔完全閉塞>3個月不能防止主要的分支受損移植靜脈退行性變易碎破TIMI血流分級0級:無灌注,堵塞相關(guān)血管完全閉塞,無造影劑通過狹窄部位.1級:少量造影劑通過病變,但不能使遠(yuǎn)端動脈血管床充分顯影2級:血流>3個心動周期才能使病變遠(yuǎn)端的動脈血管床充分顯影(30楨/秒)3級:完全灌注,≤3個心動周期遠(yuǎn)端的動脈血管床充分顯影(30楨/秒)TIMI心肌灌注分級(TMPG)0級:心肌無明顯組織灌注,罪犯血管區(qū)域無毛玻璃樣改變或心肌顯影,提示組織水平灌注低下。1級：造影劑緩慢灌注心肌，但不能從微血管排空，毛玻璃樣改變或罪犯血管區(qū)域心肌顯影不能從微血管去除，心肌顯影在開始下一個造影序列〔間隔~30秒〕時