Basic Coronary Anatomy - Paul Fefer, MD..ppt

Presentation on coronary anatomy

1. Basic Coronary Artery
Anatomy
Paul Fefer, MD.
Interventional Cardiology Unit
Sheba Medical Center, Tel Hashomer
Courtesy of Frederick Feit, MD
The Cardiovascular Research Foundation Transcatheter Cardiovascular Therapeutics
Medtronic Fellows PCI PrimerMedtronic Fellows PCI Primer

2. Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy
Sternocostal Aspect

3. Diaphragmatic Aspect
Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Right Coronary Artery
•Origin
Right aortic sinus (lower origin than LCA)
•Course
Down right AV groove toward crux of the heart, gives
off PDA (85%) from which septals arise, 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.
•Supplies
25% to 35% of Left Ventricle
Basic Anatomy

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Right Coronary Artery
•Conus Artery
usually very proximal; (~50% have a separate origin)-
courses anteriorly and upward over the RV outflow
tract toward the LAD. May be an important source of
collaterals.
•SA Nodal Artery
(~60%) usually 2nd branch of RCA-courses obliquely
backward through upper portion of atrial septum and
anteromedial wall of the RA-supplies SA node, usually
RA and sometimes LA.
Other Branches

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Right Coronary Artery
•Right Ventricular (Acute Marginal)
Branches)
Arise from mid RCA; supply anterior
RV; may be a collateral source.
•AV Nodal Artery
Arises at or near crux; supplies AV node.
•PDA
Supplies inferior wall, ventricular
septum, posteromedial papillary muscle.
Other Branches

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Right Coronary Artery
•LAO (30) Cranial(30)
particularly for distal bifurcation (AP
Cranial may be better).
•RAO
main shaft; cranial enhances distal vessels
and very proximal; caudal may help with
Shepherd’s crook.
•Lateral
bifurcations with RV branches-distal
bifurcation, particularly with cranial.
Optimal View(s)

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
LAO Cranial Angiogram of RCA
PDAPDA
Acute MarginalAcute Marginal

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RAO Angiogram of RCA

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Native RCA Lateral View
Acute Acute
MarginalMarginal
Main RCAMain RCA
Demonstrating Origin of Acute Marginal

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
AP Cranial View of Distal RCA
PDAPDA
A
V
G
r
o
o
v
e
A
V
G
r
o
o
v
e
RPL 1RPL 1
RPL 2RPL 2

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Left Coronary Artery
•Origin
upper portion of left aortic sinus just below the sinotubular
ridge. Typically 0-10 mm in length. Rarely no LM (separate
origins).
•Catheterization Technique
“The Judkins’ 4-Left coronary catheter will find the LCA
orifice unless thwarted by the operator”. Just in case-other
Judkins sizes for smaller or larger aortas; Amplatz, XB type
curves. Watch for “damping”; For separate ostia-separate
catheters, larger for Cx, or counterclockwise rotation for LAD.
•Optimal Views
LAO caudal and cranial; AP-caudal, cranial or flat. Limit
views. May need IVUS
Left Main Coronary Artery

13. Sternocostal Aspect
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14. Diaphragmatic Aspect
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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Left Anterior Descending Artery
•Course
down the anterior interventricular groove-usually
reaches apex. In 22% of cases does not reach apex.
•Branches
septals and diagonals-supply lateral wall of LV,
anterolateral papillary muscle; 37% have median
ramus (courses like 1st diagonal).
•LAD
Supplies anterolateral, apex and septum; ~45%-55%
of left ventricle.

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Left Circumflex Artery
•Origin
from distal LMCA.
•Course
down distal left AV groove.
•Branches
obtuse marginal, posterolaterals-supply
posterolateral LV, anterolateral papillary muscle. SA
node artery-38%.
•Supplies
15%-25% of LV, unless dominant (supplies 40-50%
of LV).

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Left Coronary Artery
•AP (30)Caudal
LMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD-
RAO may be useful.
•AP (40)Cranial
LMCA, LAD, diagonals, septals, distal Cx-may need RAO to
separate LAD and Cx.
•(45)LAO (35) Cranial
LMCA, LAD, diagonals, septals, and distal Cx.
•(45)LAO (30) Caudal
LMCA, Cx,and prox LAD.
•Laterals (cranial, caudal)
may be helpful.
Optimal Views

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
AP Caudal View of LCA
LADLAD
CircCirc

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
SeptalSeptal
LADLAD
CxCx
DiagonalDiagonal
AP Cranial View of LCA

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
AP Cranial LCA Angiogram
SeptalSeptal
DiagonalsDiagonals
LADLAD
LMCALMCA
CxCx

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
CircCirc
DiagonalDiagonal
LADLAD
LAO Cranial View of LCA

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
LAO Caudal View of LCA
CircCirc
LADLAD
Median RamusMedian Ramus

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Dominance:
•Definition 1:
the coronary artery which reaches the
crux of the heart and then gives off the
PDA
•Definition 2: (Allows for codominance)
the artery which gives off the PDA as
well as a large posterolateral branch

24. Left
Dominant
Circulation
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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
LCA Angiogram
Distal LADDistal LAD
Prox LADProx LAD
LMLM
OMOM
Distal CxDistal Cx
Occluded Median RamusOccluded Median Ramus
Dominant Cx AP Caudal

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
LCA Angiogram-Dominant Cx LAO-Caudal
Distal LADDistal LAD
LMLM
Prox CxProx Cx
LPDALPDA
OccludedOccluded
MedianMedian
RamusRamus
Prox LADProx LAD

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
The Coronary Arteries Are Complementary
•Large PDA Small LAD
•Huge Cx (posterolaterals)
 Small RCA continuation in AV
Groove
•Etc, etc, etc…..

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Wrap Around LAD

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Short LAD/Large RCA with Apical Extension

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
BYPASS GRAFTS
•SVG
Left coronary grafts generally arise from
left side of the aorta. Best cannulated with
Judkins’ Right, IMA, LCB or MP.
Right sided grafts-arise from right side of
the aorta-MP usually best.
•IMA
don’t forget to check subclavians.
All distal vessels must be accounted for; op notes and old films are extremely helpful.

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
SVG-OM-LAO Caudal
Demonstrating Graft Ostium
OstiumOstium

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SVG-OM 1 AP Caudal
Demonstrating Anastomosis
SVGSVG

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
LIMA to LAD
Origin from left subclavian (AP Cranial)

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LIMA to LAD
Distal Anastomosis-AP Cranial
LIMALIMA
LADLAD

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Left Subclavian Artery Stenosis

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RIMA to RCA

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RIMA to RCA

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Occluded Left-sided SVG

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Native LCA AP Caudal
Stump of original Stump of original
SVG to OM 1SVG to OM 1

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SVG to OM
Lesion 1Lesion 1
Lesion 2Lesion 2

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SVG to OM
Slight change of view to demonstrate
unequivocal severity of lesion
Lesion 1Lesion 1
Lesion 2Lesion 2

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SVG to RCA
Multipurpose Technique -LAO
SVGSVG

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Ulcerated Plaque

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
LCA AP Caudal
Severe stenosisSevere stenosis
Distal LADDistal LAD
with slow flowwith slow flow

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Thrombus In LAD
Post-NTG-Thrombus has migrated distally but still adherent
ThrombusThrombus

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AP Cranial Thrombus In LAD
ThrombusThrombus

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Embolization of Thrombus During Angiography
ThrombusThrombus

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Calcified Native RCA
(LAO Cranial)
“Bone Island” Simulating Thrombus

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Myocardial Bridging
•Almost always LAD
•Occurs in 5-12% of patients
•Usually not hemodynamically significant
Intramyocardial Segment

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Myocardial Bridging
LCA-RAO Projection
LAD DiastoleLAD Diastole LAD SystoleLAD Systole

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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.
Coronary Artery Fistula
•Origin50% RCA.
•Clinical Syndromes: CHF, endocarditis,
ischemia, and rupture of aneurysmal fistula.
50% are asymptomatic.
•Drainage: RV-41%; RA-26%; PA-17%;
LV-3%, and SVC-1%.

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Coronary Artery Fistula
LCA-RAO Projection
LAD to PA Fistula
LADLAD
PAPA
FistulaFistula

53. Anomalous Origin of LCA from the
Right Sinus of Valsalva
•Rare
•Course relative to great vessels is variable
and must be defined. If interarterial,
surgical therapy is warranted.
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54. Anomalous Origin of RCA from Left
Coronary Sinus
•Rare
•Arises anterior to the origin of the LCA
•Engage with Left Amplatz, or Left Judkins’
•RCA runs an interarterial course
•Usually benign
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55. Normal and Anomalous
Origins of the Coronary
Arteries
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Benign Anomalies (0.5-1%)
•Left Circumflex from right Sinus of Valsalva
Most common “benign” anomaly
Circumflex courses behind aorta
•High Anterior Origin of RCA
Above sinotubular ridge

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Anomalous Circumflex Artery