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1、支架精细显影StentBoost在日常DES中的应用,刘健 教授北京大学人民医院 心脏中心,支架因素：-支架表面-药物支架-支架材料-支架重叠,病变因素：-血管直径、长度-血栓-斑块特征-分支-钙化-完全闭塞,手术操作因素:-剥离-支架与学管壁帖服不完全-支架膨胀,凝血因素：-凝血因子活性-血小板聚集抑制因子-对抗凝治疗不敏感-过早停止抗凝治疗,病人因素：-药物的反应/相互作用-基因多样性-左室功能-急性冠状动脉综合症-肾功能衰竭-糖尿病,支架 血栓形成,影响DES 内血栓形成的因素：,Windecker and Meier.Circulation 2007;116:1952-65,Stent
2、 underexpansion and significant residual reference segment stenosis Fujii et al.J Am Coll Cardiol 2005;45:995 8,DES不完全膨胀的血栓形成(1 年),最小支架 CSA(mm2),(Okabe et al.Am J Cardiol 2007;100:615-20)(Liu et al.JACC Interventions,in press),#DES 血栓形成,0,5.0,20.0mm,IVUS:支架不完全膨胀,IVUS花费昂贵，VS StentBoost 平民花费,StentBoos
3、t enhances the image quality of stents by integrating a series of non-contrast images from a single run after motion compensation.This enhanced image is subtracted from a contrast-filled image from the same run.The enhanced subtracted image shows improved contrast of the stent and shows the relation
4、 between the location of the stent and the vessel wall.The visualization dynamically fades in and out,between the stent image and the vessel image,in order to show the relationship between the two.,StentBoost:基本原理,6,StentBoost:基本原理,click to play movie,StentBoost R2,A StentBoost image is automaticall
5、y generated from a single standard acquisition at 15 frames per second consisting of 2 seconds without contrast agent injection followed by 2 seconds with contrast injection at 3 mL/sec for a total of 6 mL of contrast agent.During acquisition the balloon is left in place because the algorithm uses t
6、he balloon markers for motion compensation of the acquired images,thereby allowing stent enhancement and display of the stent in relation to the surrounding vessel wall.,StentBoos 基本原理,Frame 1,Frame 1&2,Translation,Rotation,Stretching,能够精确细致的显示支架的位置、形态、膨胀、展开、贴壁、支架间重叠状况,Stentboost是什么？:来自Philips 的独一无二
7、的功能,StentBoost 是如何工作的？,时间短，计量低：和普通的cine 一样一键式完成:自动的支架探测 自动支架增强自动支架显示存档形式:被增强的静态支架图像 DICOM 动态的支架及内腔图像 windows 可播放的,10,StentBoost:临床关键优势,click to play movie,StentBoost R2,11,StentBoost Release 3:增强了以下功能,click to play movie,12,StentBoost Release 3,你可以像这样如此轻松的 观看支架被放置的整个过程,click to play movie,click to p
8、lay movie,13,StentBoost Release3对支架膨胀的评估更精确,-更好的显示支架和血管的贴壁情况-提高了显示更细微结构的IQ,click to play movie,14,实现支架位置放置的精准,精确的支架位置选择分支血管分支血管开口高质量的图像使再复杂的血管关系内的支架也能一目了然,click to play movie,click to play movie,15,校验支架展开,支架展开和血管腔内关系增强钙化斑块的显示,click to play movie,click to play movie,16,校验支架展开,支架展开和血管壁形状关系支架变成锥形,click
9、 to play movie,click to play movie,17,鉴别并发症,支架破裂可用肉眼评估和检查,click to play movie,用StentBoost观察放置在 LAD 支架的情况,支架放置后的结果（3.5mm/14 atm),Result after 3.5mm balloon inflation at 16 atm.,用StentBoost观察放置在 LAD 支架的情况,Result after 3.5mm balloon inflation at 24 atm.,用StentBoost观察放置在 LAD 支架的情况,21,总结,当用QCA作比较时，对于支架膨胀
10、的评估stentboost和 IVUS 显示了高度相关一致性。另外，stentboost 比IVUS有更多的潜在优势。Stentboost 对绝大多数支架放置病例来说是非常有价值的。StentBoost 能清晰的显示支架的膨胀、贴壁情况，也能够提示血管内的钙化斑块和明确清晰显示病变端周围血管分支情况。,Thank you for your attention!,23,Stent Visualization,Would it not be great to have a fast,cost-effective assessment of the stent,right under your fi
11、ngertip?See the difficult DESSee Stent in Stent placementSee the stent in the lumenSee the cracksSee the under deploymentAnd all without IVUS?,24,Why should I use StentBoost?,“SB had superior correlations for stent expansion measured by IVUS when compared with QCA.Correlations of minimum stent diame
12、ter were highest between IVUS and SB(r=0.75;P 0.0001)when compared with QCA and IVUS(r 0.65;P 0.0001).”Mishell et al,Catheterization and Cardiovascular Interventions 69:8493(2007)“The use of stent boost after each stent implantation was deemed useful in 72%of cases”.Ohanessian et al,RSNA 2008 Circul
13、ation.2008;118:S_958;abstract 4909.“StentBoost Subtract enabled an improved visualization of the good expansion of the stent and of its apposition to the vessel wall,clearly revealing also a calcified plaque in the LAD on the opposite site in respect to the origin of the diagonal branch”Agostini et
14、al.Int J Cardiol(Epub ahead of print),How does StentBoost compare to IVUS?,Conclusions of clinical study on 30 patients:StentBoost has good correlations with IVUS(R=0,77)Determination of Adequate Coronary Stent Expansion Using StentBoost,a Novel FluoroscopicImage Processing TechniqueJacob M.Mishell,
15、MD,et al.Published in CCI 69:8493(2007),26,”Positive correlation between StentBoost and IVUS”Dr Michaels USCF Dec.2006“StentBoost shows several potential advantages when compared with IVUS”Dr Michaels USCF Dec.2006“StentBoost is challenging IVUS”Dr van Langehoven,Middelheim,Belgium“StentBoost has ch
16、anged our clinical pratise”Dr van Langehoven,Middelheim,Belgium,StentBoost use during daily PCI procedure in DES era,Liu,Jian MDPeking University Peoples Hospital,Heart Center,Device factors-Surface-Drugs-Polymer-Stent overlap,Lesion factors-Vessel size/length-Thrombus-Plaque characteristics-Bifurca
17、tion-Calcification-Total occlusions,Procedural factors-Dissection-Incomplete stent apposition-Stent expansion,Platelet and Coagulation factors-Coagulation activity-Inhibition of platelet aggregation-inadequate response to anti-platelet therapy-premature anti-platelettherapy discontinuation,Patient f
18、actors-Drug response/interactions-Gene polymorphism-LV function-Acute coronary syndrome-Renal failure-Diabetes,STENT THROMBOSIS,Multifactorial Nature of DES Thrombosis,Windecker and Meier.Circulation 2007;116:1952-65,Stent underexpansion and significant residual reference segment stenosis Fujii et a
19、l.J Am Coll Cardiol 2005;45:995 8,Stent Underexpansion in Early(1 year)DES Thrombosis,Minimum stent CSA(mm2),(Okabe et al.Am J Cardiol 2007;100:615-20)(Liu et al.JACC Interventions,in press),#with DES Thrombosis,0,5.0,20.0mm,IVUS:Stent underexpasion,But IVUS cost money.And StentBoost cost a little,S
20、tentBoost enhances the image quality of stents by integrating a series of non-contrast images from a single run after motion compensation.This enhanced image is subtracted from a contrast-filled image from the same run.The enhanced subtracted image shows improved contrast of the stent and shows the
21、relation between the location of the stent and the vessel wall.The visualization dynamically fades in and out,between the stent image and the vessel image,in order to show the relationship between the two.,StentBoost:basic principle,34,StentBoost:basic principle,click to play movie,StentBoost R2,A S
22、tentBoost image is automatically generated from a single standard acquisition at 15 frames per second consisting of 2 seconds without contrast agent injection followed by 2 seconds with contrast injection at 3 mL/sec for a total of 6 mL of contrast agent.During acquisition the balloon is left in pla
23、ce because the algorithm uses the balloon markers for motion compensation of the acquired images,thereby allowing stent enhancement and display of the stent in relation to the surrounding vessel wall.,StentBoost basic principle,Frame 1,Frame 1&2,Translation,Rotation,Stretching,Having the ability to
24、accurately visualize stent deformation,deployment,expansion,apposition to the vessel wall and overlap with other stents,What is Stentboost:A Unique Philips Product,How does StentBoost work?,Short run with normal cine doseNo user interaction required:Automatic stent detection Automatic stent enhancem
25、entAutomatic diplayed from acquisitionArchive:Enhanced still image of stentArchived as DICOM secondary captureDynamic image of stent with relation to lumenArchived as windows compatible movie,38,StentBoost:key benefits,click to play movie,StentBoost R2,39,StentBoost:Enhanced benefits in R3,click to
26、play movie,40,StentBoost Release 3,Stent placement&deployment Like you have never seen before,click to play movie,click to play movie,41,StentBoost Release 3:improved assessment of stent deployment,New:Improved stent visualisation withclear relation to the vessel lumenEnhanced visibility of stentsEx
27、cellent IQ,even thin stent strutsAnd stent placement in relation tothe vessel lumen,click to play movie,42,Improves stent positioning in bifurcations,Accurate stent placement in relation to vessels and other stents:BifurcationOstium of main branchHigh Image quality enables:even crossing wire through
28、 struts,click to play movie,click to play movie,43,Verify deployment,Stent deployment in relation with the vessel lumen:enhanced visualisation of calcified plaque,click to play movie,click to play movie,44,Verify deployment,Stent deployment in relation with the vessel wall:stent tapering,click to pl
29、ay movie,click to play movie,45,Identify complications,Stent fractureassessment and visual check on stent deployment,click to play movie,PCI of LAD with DES-stentBoost,Result after placement of 3.5mm stent at 14 atm.,Result after 3.5mm balloon inflation at 16 atm.,PCI of LAD with DES-stentBoost,Resu
30、lt after 3.5mm balloon inflation at 24 atm.,PCI of LAD with DES-stentBoost,49,Conclusions,StentBoost had superior correlations for stent expansion measured by IVUS when compared with QCA.StentBoost shows several potential advantages when compared with IVUSThe use of stentBoost after each stent impla
31、ntation was deemed useful in most of cases.StentBoost Subtract enabled an improved visualization of the good expansion of the stent and of its apposition to the vessel wall,clearly revealing also a calcified plaque in the vessel and can clearly identify the origin of side branch.,Thank you for your
32、attention!,51,Stent Visualization,Would it not be great to have a fast,cost-effective assessment of the stent,right under your fingertip?See the difficult DESSee Stent in Stent placementSee the stent in the lumenSee the cracksSee the under deploymentAnd all without IVUS?,52,Why should I use StentBoo
33、st?,“SB had superior correlations for stent expansion measured by IVUS when compared with QCA.Correlations of minimum stent diameter were highest between IVUS and SB(r=0.75;P 0.0001)when compared with QCA and IVUS(r 0.65;P 0.0001).”Mishell et al,Catheterization and Cardiovascular Interventions 69:84
34、93(2007)“The use of stent boost after each stent implantation was deemed useful in 72%of cases”.Ohanessian et al,RSNA 2008 Circulation.2008;118:S_958;abstract 4909.“StentBoost Subtract enabled an improved visualization of the good expansion of the stent and of its apposition to the vessel wall,clear
35、ly revealing also a calcified plaque in the LAD on the opposite site in respect to the origin of the diagonal branch”Agostini et al.Int J Cardiol(Epub ahead of print),How does StentBoost compare to IVUS?,Conclusions of clinical study on 30 patients:StentBoost has good correlations with IVUS(R=0,77)D
36、etermination of Adequate Coronary Stent Expansion Using StentBoost,a Novel FluoroscopicImage Processing TechniqueJacob M.Mishell,MD,et al.Published in CCI 69:8493(2007),54,”Positive correlation between StentBoost and IVUS”Dr Michaels USCF Dec.2006“StentBoost shows several potential advantages when compared with IVUS”Dr Michaels USCF Dec.2006“StentBoost is challenging IVUS”Dr van Langehoven,Middelheim,Belgium“StentBoost has changed our clinical pratise”Dr van Langehoven,Middelheim,Belgium,
