Gregg W. Stone， MD
　　哥伦比亚大学医学中心/纽约长老教会医院，心血管研究和教育部主任
　　International Circulation: Generally in China， angiography is the sole visualization equipment used for DOME PCI. How do you think we should decide when to us IVUS for PCI interventions?
　　Prof. Gregg Stone: We have found IVUS to be invaluable in the CATH lab. Of course angiography is always the basis of where we see our lesions and how we guide our procedures， but we always have to decide if there is disease that we are not seeing in the artery or is the artery bigger than it actually looks. By eye we are not very good at seeing all the details inside the coronary artery because an angiogram is basically just a look at the lumen of the artery. It doesn’t show the endothelial wall. IVUS is every important because you see the external elastic membrane and the whole vessel wall allowing the clinician to see how much plaque there is and the size of the vessel This tells you how large of a balloon or stent the vessel can actually accommodate， and you can see where the disease starts and stops. By doing IVUS before the procedure， the first big benefit is that we occasionally find a lesion we didn’t know about previously nor expect. The angiogram looked like it was only a mild disease while IVUS showed that it was more severe. If we don’t treat that lesion as well we  will not be able to help the patient. Second， and most importantly， IVUS shows us where to start the stent， where to stop the stent， and how big in diameter a stent can be. Our eye may assess that it is only a 2.5mm vessel by angiography， but the vessel wall visualized in IVUS may measure to 3.5mm， in which case we can very easily and safely place a 3mm stent. Since the diameter of the stent is the number one predictor of freedom of both restenosis and stent thrombosis， it is very important to try to put the largest diameter stent in as possible.
　　《国际循环》：在中国通常情况下，血管造影是PCI术中唯一的影像设备。您认为应该如何决定在PCI术中何时使用IVUS？
　　Prof. Gregg Stone：我们早已发现在导管室中IVUS具有无可比拟的价值。当然，在观察病变和指引操作方面，血管造影是最基础的手段；但我们经常需要确定是否存在我们事先没有看到的病变，或血管是否比看起来的更为粗大。仅凭肉眼无法看到冠状动脉内所有的细节信息，因为血管造影基本上只是显示了动脉官腔，而不能显示内壁的情况。IVUS非常重要，通过IVUS我们可以看到外弹力膜和整个血管壁，使得临床医生能够看到有多少斑块、血管的大小，从而告诉我们可容纳何种规格的球囊和支架，可明确显示病变的其实和终末部位。在术前进行IVUS检查大有裨益，首先，通过IVUS我们偶尔会发现之前我们并未发现的病变。有可能血管造影显示只是一处轻微的病变，而IVUS却显示病变非常严重，如果不作处理，将对患者没有任何帮助。第二，最重要的是，IVUS可告诉我们支架释放时应始于何处，止于何处，以及该选用直径多大的支架。我们的肉眼通过血管造影估计为直径2.5 mm的血管，在IVUS下可能测量结果为3.5 mm，这种情况下我们就可以非常容易和安全地置入直径为3 mm 的支架。由于支架直径是无再狭窄和无支架内血栓形成的第一预测因子，因此置入直径尽可能大的支架至关重要。
　　International Circulation:  Do you use IVUS in all of your interventions?
　　Prof. Gregg Stone: I use IVUS in about 50-60%. The very simple cases， with very short， focal lesions in a large vessel， where you are already going to put in a 3.5-4mm stent， IVUS is not really needed. Any time there is small vessel disease or long， complex lesions inside vessels， then IVUS is a very useful tool. For anyone doing complex intervention， we think IVUS is essential. For left main artery interventions， IVUS is also essential. Finally， for bifurcation disease interventions IVUS is a critically important tool.
　　《国际循环》：您在所有介入手术中均使用IVUS?
　　Prof. Gregg Stone：当然不是。我使用IVUS的患者比例大概50%~60%。对于非常简单的病例，如较大的血管内短而局限的病变，你计划置入1枚直径3.5-4mm的支架，这种情况IVUS并不是必须的。当面对小血管病变或长的复杂病变时，IVUS是非常有用的工具。我们认为任何人施行复杂介入术时，IVUS都是必须的；对左主干介入操作同样如此。最后要强调，在进行分叉病变介入手术时，IVUS是十分重要的辅助工具。
　　International Circulation: You are about to moderate a session this afternoon on bifurcation， IVUS， and FFR. Which do you think is more important or in what cases are IVUS or FFR important for bifurcations?
　　Prof. Gregg Stone: We use them both， and they are both very important. The FFR tells you the physiological significance of a lesion and FFR is the best test to tell you when a lesion does not need to be treated. That is essential because over the last decade we have probably been stenting too many lesions. If we treat every lesion on all of the coronary artery disease that we see， we are going to be seeing high rates of restenosis or thrombosis. Instead we need to  be treating the ischemia producing lesions， and the FFR tells us which ones those are. If we defer 50%， 60%， or 80% stenosis that the FFR says don’t need to be treated， then the patient will have a better long-term outcome. We use FFR to plan which lesions really need to be treated， then we use IVUS for the lesions we are going to treat in order to guide the procedure. How large of a stent? How long of a stent?  Do we need to treat the bifurcations or should they be left alone?  All these questions can be answered with these complementary tools， FFR and IVUS.
　　《国际循环》：今天下午您将主持主题为“分叉病变、IVUS和FFR”的专题分会，您认为对分叉病变那一项更为重要？或者说，IVUS或FFR对什么样的病例更重要？
　　Gregg Stone：这2项技术我们都使用，都非常重要。FFR告诉我们一处病变的生理学意义，并且是告诉我们一处病变不需要治疗的最好的检验方式。这非常重要，因为过去十年中我们可能对太多的病变置入了支架。如果我们对所看到的所有冠状动脉病变都置入支架，那么我们将会面临非常高的再狭窄或血栓形成发生率。我们需要治疗的是那些导致缺血的病变，而FFR能够告诉我们哪些才是这样的病变。如果我们对50%、 60%或80%的FFR显示不需治疗的狭窄病变推迟置入支架，患者将获得很好的远期结果。我们使用FFR筛选哪些病变时真正需要治疗的，然后使用IVUS观察将要治疗的病变以指导操作。应选用直径多大以及多长的支架？是否需要治疗这例分叉病变，还是留待观察？使用FFR和IVUS这两种互补的技术，能够回答上述所有问题。
　　International Circulation: If you have a bifurcation lesion， you use FFR?
　　Prof. Gregg Stone: No， not every single time. If the stenoses are 90% or greater， the FFR is almost always positive and using it is not really needed. If the stenoses are 70-90%， then the FFR is positive in about 2/3rd of cases， so we use our judgment whether to use FFR in those cases or not. For instance， if the lesion is 85% then we would not use FFR， but if it is at 71% then we certainly do use FFR. When stenoses are less than 70% then the FFR is positive in only about 1/3rd of cases. It is in these cases when FFR should be routinely used to determine if the mild to moderate lesions really need to be treated.
　　《国际循环》：当您有分叉病变病例，您会应用到FFR吗？
　　Prof. Gregg Stone：并非每次都使用。如果病变狭窄率超过90%，FFR几乎都会是阳性结果，这种情况下实际上并不需要进行检测。对狭窄率70%～90%的病变，约2/3rd的病例FFR检测为阳性结果，这时我们根据自己的判断决定是否进行FFR检测。例如，对狭窄85%的病变我不需使用FFR；但对狭窄71%的病变，我们当然需要使用FFR。当病变狭窄率<70%时，仅有1/3rd的FFR检测结果为阳性。对这些病例应常规进行FFR检测，以决定这些轻中度狭窄病变是否真正需要治疗。
 

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