Coronary anatomy and angiographic views

For beginners like me

1. Coronary anatomy and Angiographic views Presenter: Dr Thanigai arasu E DM Cardiac anaesthesia(1 st year PG)

2. History 1650= Vieussens described first. 1799=Edward Jenner established the relationship between the coronary artery and angina pectoris. 1809=Allan Burns described the same. 1958= Maron Sones performed the first selective coronary arteriography . 1968=Rene Favalan and Dudley Johnson introduced the coronary artery bypass surgery.

3. The coronary arteries and their major branches are sub- epicardially located

4. Lt Main coronary Artery (LMCA) - from the left coronary sinus just below the sinotubular ridge passes behind the pulmoary trunk, - forwards and to the left between pulmonary trunk and left auricle-bifurcates into LAD and LCx . 1-25mm in length & Diameter of 2-5.5mm(mean of 4mm) . Short if it is <1mm. Trifurcates in 1/3rd : Ramus intermedius / median artery/ left diagonal artery/straight LV artery Rare variations – absent LMCA/ pentafurcation

5. Contd.. LAD runs in the anterior IV groove towards the apex and it terminates -Beyond the ventricular apex along the diaphragmatic aspect in 78%-Type III -At the apex-Type II -Before the apex in 22%-Type I 10-13cmin length, 2-5mm in diameter(mean of 3.6) Branches: 1. septal branches are vary in No and size originates at a right angle- anterosuperior 2/3 rd IVS(Inter ventricular septum) 2. 1-3 diagonal course laterally over the free wall of lt ventricle in the angle between Lad and LCx-anterolateral portion of LV & AL papillary muscle Angiographical classification: Proximal-origin to 1 st major septal perforator Mid-1 st perforator -D2 Distal-D2 to end.

6. Contd.. Lcx travels in the left AV groove and finally reaches crux of the heart(Posterior part of AV groove), it anastomoses with branches of the RCA. 6-8cm in length, 1.5-5.5mm in diameter(mean of 3mm) . Branches: LA branches: 1-2 supplies Left atrium OM : 1-3 in no supplies lateral free wall of LV In case of Left dominant(8%)- PDA, PLV, SA nodal (40-50%), AV nodal Artery(10-20%). Angiographical classification: proximal-origin to OM1 Mid: OM1-OM2 Distal: OM2-end.

7. contd.. RCA arises- Rt CS - lower in position than that of Lt CS, Course- forwards and to the Rt between the pulmonary trunk and Rt auricle, - winds round the inferior border of the heart to reach the diaphragmatic surface of the heart. Here, it passes upwards and to the left in the right posterior coronary sulcus and reaches crux of the heart and terminates by anastomosing with the branches of the Lcx . Branches: 1. Conus A-1 st branch- infundibulum of RV, but in 40-50%-separate ostium in the Rt CS(3 rd coronary A) 2. SA nodal A-50-60% runs along the rt atrium to SVC where it encircles in a clock wise or anticlockwise before it penetrates the SA node—supplies RA. 3. Right ventricular branch-AM-supplies anterior wall of rt ventricle. In Right Dominant circulation(85%) – AV nodal A-AV node,

8. PDA- postero inferior 1/3 rd of IVS & PM papillary muscle, communicates with the of the LAD artery around the apex. Where there is a major blockade of the LAD, a patent right dominant system can supply the LAD region in a retrograde way. PLV- posterolateral portion of LV. Angiographic classification of RCA. Proximal - Ostium to 1 st main RV branch Mid - 1 st RV branch to acute marginal branch Distal - acute margin to the crux

9. Dominance(Crux cordis ): 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 Super dominant RCA- in type 1 LAD the larger and longer PDA from RCA supplies the ventricular apex also.

10. RA-RCA. LA-Left circumflex RV=Anterior portion adjacent to the interventricular septum-branches of LAD; rest-RCA LV= 50% from the LAD. 25% from the left circumflex, 25%-posterior descending a.(from rt. Coronary or the left circumflex). . The anterolateral papillary muscle-blood supply - diagonal branches of LAD. The posterior papillary muscle-dual blood flow from circumflex and terminal branches of RCA. Sinus node-In majority by RCA, in a small proportion by the circumflex. AV node-The first posterior perforator of the PDA. Bundle of His-dual blood supply from both the PDA and LAD, more resistant to ischemia than the AV node. Rt. Bundle-LAD and RCA. Left bundle-mainly from the diagonals. REGIONAL MYOCARDIAL BLOOD SUPPLY

11. ? Coronary artery Variation vs Anomalies A broad spectrum of variations of which some may cause adverse effects Most of the coronary variations may have no clinical implications as can be proven by myocardial perfusion studies. The regional distribution of a coronary artery, rather than its absolute origin and characteristics.

12. Coronary artery variations Definition of a coronary artery is not based on its origin and proximal course , but by focusing on its intermediate and distal segments/ its dependent microvascular bed. Angelini P – Coronary artery anomalies – current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines. Tex Heart Inst J 2002;29:271-278

13. Level of variables 1) Ostium 2) Size 3) Proximal course 4) Mid-course 5) Intramyocardial ramifications 6) Termination Anomalies without a shunt: 1. Abnormal number : 1/ 3/ 4 ostia 2. Anomalous origin: a) Outside SOV b) Independent origin from same sinus c) Opposite sinus d) Other artery 3. Myocardial bridge 4. Segmental stenosis / hypoplasia Anomalies with shunt : 1) Fistula 2) APOCA C. Aneurysms

14. Abnormal position of ostia Coronary orifice below the cuspal margin: - 10% RCS 15% LCS Coronaries above the sinotubular jn ~ 6% - leads to difficult cannulation , esp RCA with a high anterior ostium .

15. Absent LMCA ~0.4% - 1 ostia at the LCS/ 2 ostia in LCS/ 1 ostia in LCS & other RCS Increased incidence of Left dominance 6% incidence of bridging Not usually associated with CHDs Similar incidence of atherosclerosis Difficulty in selective cannulation Topaz et al.  Absent left main coronary artery: angiographic findings in 83 patients with separate ostia of the left anterior descending and circumflex arteries at the left aortic sinus. Am Heart J.1991 Aug;122(2):447-52.

16. Shepherd’s-crook RCA ~5% Acute superiorly angled take-off of the RCA from the aorta. Difficult RCA lesion angioplasty Ethan Halpern . Cardiac CT . Functional anatomy.

17. Dual LAD (Duplication) ~0.13 - 1% of normal hearts Proximal LAD (LAD proper) bifurcates early into a short and long LAD - Type I : Short LAD in AIVS, Long LAD on prox AIVS, LV side, distal AIVS -Type II : Short LAD in AIVS, Long LAD on prox AIVS, RV side, distal AIVS -Type III: Short LAD in AIVS, Long LAD intra- myocardially in septum -Type IV: Very short LAD proper and short LAD, Long LAD from RCA Spindola -Franco H et al. Dual left anterior descending coronary artery: angiographic description of Important variants and surgical implications. Am Heart J 1983:105;445–55.

18. Level of variables 1) Ostium 2) Size 3) Proximal course 4) Mid-course 5) Intra-myocardial ramifications 6) Termination MSCT with retrospective ECG gating is now considered the gold standard for characterization of coronary anomalies. Prompt a search for underlying CHDs

19. LCA from PA Large RCA Collaterals to LAD LAD arising from PA

20. Normal and Anomalous Origins of the Coronary Arteries

21. Coronary artery Ectasia 1 - 5% in angiographic series, more in males 20- 30 % are congenital Dilatation of a segment to at least 1.5times of the adjacent normal coronary artery.

22. Collateral Circulation-Development Preexisting arterial anastomosis seen in intracoronary/ intercoronary levels in abundance. Significant in forming collaterals in CAD. Intracoronary : 1-2cm X 20- 250 micm Inter-coronary: 2-3 cm X 20-350 micm First 24 hours-passive widening One day-3 weeks cellular proliferation, luminal diameter increases 10 fold. 3 weeks-6 months more cellular proliferation and development of extracellular matrix; channels may reach 1mm in caliber. Ischemia and occlusion are the only triggers. Usually need very high grade coronary artery occlusion for collaterals to be angiographically apparent.

23. Collateral “Connections” Occur where coronary arteries are in proximity Distal LAD  Distal PDA Cx AV groove  R AV groove Septal  Septal Marginal  Marginal Diagonal  Marginal Also Bridging collaterals-associated with chronicity Kugel’s artery-prox RCA to distal RCA via AV groove Always look for conus to LAD collaterals when LAD is occluded and appears uncollateralized.

24. Collateral Development After RCA Occlusion

25. Collateral Pathways After LAD Occlusion

26. Collateral Pathways After Circumflex Occlusion

27. Classification of Collaterals 0 No epicardial filling at baseline or during balloon inflation 1 No epicardial filling at baseline with partial epicardial filling during balloon inflation 2 Partial baseline filling with partial or complete filling during balloon inflation 3 Complete epicardial filling at baseline Rentrop Grade “ Recruitable collaterals”—collaterals which can become angiographically apparent only during occlusion, such as those observed during PTCA. Collaterals can be dilated by nitrates, B-adrenergic agents, NO and prostacyclin

28. Recruitable Collaterals RCA Injection during LAD PTCA RCA angiogram demonstrates complete filling of LAD. No collaterals were apparent prior to balloon inflation.

29. An extensive intercommunicating network by a. the coronary sinus b. the anterior right ventricular veins. c. the thebesian veins. Coronary sinus= in the left posterior AV groove-drains predominantly the left ventricle and the left atrium. Tributaries:a )The anterior inter-ventricular vein-ends as great cardiac v b) The middle cardiac vein-from the posterior interventricular region. c) the oblique vein of Marshell -from the posterior aspect of left atrium. - opens into the rt.atrium between the orifice of IVC and septal tricuspid leaflet. VENOUS DRAINAGE

30. Contd … The anterior cardiac v.-2-4 in no. They drain the anterior right ventricular wall and end at the base of the right atrium. The small cardiac v.-receives from rt.atrium and opens into RA. The thebesian veins-tiny venous outlets draining the myocardium directly into the cardiac chambers(rt. Atrium and rt.ventricle ). INNERVATION Sympathetic: from superior, middle and inferior cervical ganglia+ upper 5 ganglia of the symp.chain . Para- symathetic : nodose ganglion. At the heart, both mingle to form cardiac plexus-superficial and deep portion.

31. 5% of the blood flow of the total cardiac output(250-275ml/min). AV oxygen content difference=10 ml/100 ml(5 ml/100 ml in other vascular beds). Oxygen consumption-25 ml/min.(beating heart at rest). -6 ml/min(non-beating heart). -0.12 ml/min(for electrical activation)] Distribution of blood volume and O2 consumption

32. Anatomical factor: arranged as a) epicardial conductance vessels (constrict to alpha stimulation and dilate to NTG.) b) intramyocardial resistance vessels(at right angles to the above). c) subendocardial plexus of vessels-dense capillary network of about 4000 capillaries/sq.mm, not uniformly patent-pre-capillary sphincters serve a regulatory role-opens out when myocardial demand increases. Under basal conditions, blood flow to the subendocardium / subepicardial layer=125:1 (maximal preferential dilatation of the subendocardial plexus of vessels. Significance: In the presence of a significant coronary artery obstruction, subendocardial vessels can’t dilate further and suffer the most by way of ischemia. REGULATION OF THE CORONARY BLOOD FLOW

33. CPP = AoDP -LVEDP All organs are perfused during systole except the LV(since the resistance vessels are compressed during systole). RV-thinner ventricle. Receives its major blood flow during systole.

34. Local metabolism: primary controller. Local arterial vasodilatation in response to muscle need for nutrition. Chemical agents responsible are: a) adenosine b) potassium ions c) hydrogen ions d) bradykinin e) prostaglandins.PGI2 and PGE2 . Oxygen lack: opening of ATP dependent K+ channels-hyper-polarization- Ca2+ channel opening prevented-vasodilatation . Auto-regulation : At perfusion pressures from 60-130 mm of Hg, CBF is the same( myogenic , metabolic factor and release of endothelial vaso -active factors are implicated ). Neural factor: α - vaso -constriction ß- vaso -dilatation. Para symp -dilates Endothelial control: EDRF(released by several stimuli), prostacyclin , endothelin . CONTROL OF CVR

35. Indications Known or suspected CAD (Class I and III only) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B CCS class III and IV angina on medical treatment High-risk criteria on noninvasive testing regardless of anginal severity Patients who have been successfully resuscitated from sudden cardiac death or have sustained (>30 seconds) monomorphic ventricular tachycardia or non-sustained (<30 seconds) polymorphic ventricular tachycardia Angina in patients who are not candidates for coronary revascularization or in whom revascularization is not likely to improve quality or duration of life As a screening test for CAD in asymptomatic patients After CABG or angioplasty when there is no evidence of ischemia on noninvasive testing Coronary calcification on fluoroscopy, electron beam computed tomography, or other screening tests without criteria listed above A B C C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

36. Indications Patients With Nonspecific Chest Pain I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B High-risk findings on noninvasive testing Patients with recurrent hospitalizations for chest pain who have abnormal (but not high-risk) or equivocal findings on noninvasive testing All other patients with nonspecific chest pain B C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

37. Indications Patients With Unstable Acute Coronary Syndromes (Class I and III only) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures) An early invasive strategy is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events An early invasive strategy is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization An early invasive strategy is not recommended in patients with acute chest pain and a low likelihood of ACS An early invasive strategy should not be performed in patients who will not consent to revascularization regardless of the findings A C Source: Anderson JL et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1–157 C C

38. Indications Patients With STEMI (Class I and III only) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B Diagnostic coronary angiography should be performed: In candidates for primary or rescue PCI In patients with cardiogenic shock who are candidates for revascularization In candidates for surgical repair of ventricular septal rupture (VSR) or severe MR In patients with persistent hemodynamic and/or electrical instability Coronary angiography should not be performed in patients with extensive comorbidities in whom the risks of revascularization are likely to outweigh the benefits A C Source: Antman EM et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2004. Available at www.acc.org/clinical/guidelines/stemi/index.pdf. C A

39. Indications Patients With Post-revascularization Ischemia (Class I and III only) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B Suspected abrupt closure or subacute stent thrombosis after percutaneous revascularization. Recurrent angina or high-risk criteria on noninvasive evaluation within 9 months of percutaneous revascularization Symptoms in a post bypass patient who is not a candidate for repeat revascularization Routine angiography in asymptomatic patients after percutaneous transluminal coronary angioplasty (PTCA) or other surgery, unless as part of an approved research protocol C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

40. Indications Perioperative Evaluation Before (or After) Noncardiac Surgery (Class I and III only) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B Evidence for high risk of adverse outcome based on noninvasive test results Angina unresponsive to adequate medical therapy Unstable angina, particularly when facing intermediate or high-risk noncardiac surgery Equivocal noninvasive test result in a high-clinical- risk in patients Low-risk noncardiac surgery, with known CAD and no high-risk results on noninvasive testing Asymptomatic after coronary revascularization with excellent exercise capacity (>7 METs) Mild stable angina with good left ventricular function and no high-risk noninvasive test results Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (eg, LVEF <0.20), or refusal to consider revascularization. Candidate for liver, lung, or renal transplant >40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome B C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357 C C C C

41. Indications Patients With Valvular Heart Disease (Class I and III only) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III Before valve surgery or balloon valvotomy in an adult with chest discomfort, ischemia by noninvasive imaging, or both Before valve surgery in an adult free of chest pain but of substantial age and/or with multiple risk factors for coronary disease Infective endocarditis with evidence of coronary embolization Before cardiac surgery for infective endocarditis when there are no risk factors for coronary disease and no evidence of coronary embolization In asymptomatic patients when cardiac surgery is not being considered Before cardiac surgery when preoperative hemodynamic assessment by catheterization is unnecessary, and there is neither preexisting evidence of coronary disease nor risk factors for CAD B C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357 C C

42. Indications Patients With Congenital Heart Disease (Class I and III only) I I IIa IIb III I I IIa IIb III I I IIa IIb III IIa IIb III Before surgical correction of congenital heart disease when chest discomfort or noninvasive evidence is suggestive of associated CAD Before surgical correction of suspected congenital coronary anomalies such as congenital coronary artery stenosis, coronary arteriovenous fistula, and anomalous origin of left coronary artery Forms of congenital heart disease frequently associated with coronary artery anomalies that may complicate surgical management Unexplained cardiac arrest in a young patient In the routine evaluation of congenital heart disease in asymptomatic patients for whom heart surgery is not planned B C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357 C C C

43. Indications Patients With CHF (Class I and III only) I I IIa IIb III I I IIa IIb III I I IIa IIb III IIa IIb III CHF due to systolic dysfunction with angina or with regional wall motion abnormalities and/or scintigraphic evidence of reversible myocardial ischemia when revascularization is being considered Before cardiac transplantation CHF secondary to postinfarction ventricular aneurysm or other mechanical complications of MI. CHF with previous coronary angiograms showing normal coronary arteries, with no new evidence to suggest ischemic heart disease B C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357 C C

44. There are no absolute contraindications to cardiac catheterization Relative contraindications include: Coagulopathy (Radial approach can be attempted based on urgency) Decompensated congestive heart failure Uncontrolled hypertension Pregnancy Inability for patient cooperation Active infection Renal failure Contrast medium allergy Contraindications

45. Conscious sedation using a narcotic and a benzodiazepine Vascular access: Either femoral (described in the section on vascular access and closure devices), radial, or brachial Flush the selected diagnostic catheter with saline to ensure an air-free system Once arterial access is obtained (as described in the section on vascular access and closure devices) a catheter of appropriate size and configuration is advanced over a 0.035 or 0.038 inch guidewire Once in the ascending aorta, the guidewire is removed, the catheter allowed to bleed back to remove any thrombus or atherosclerotic debris The catheter is then connected to a manifold assembly connected to a pressure transducer for continuous central pressure monitoring The catheter is flushed to ensure an air-free system Equipment & Technique

46. Zeroing and referencing : The transducer should be opened to air to zero the system. Care must be taken to ensure that the pressure transducer is at the level of phlebostatic axis, which is roughly the midportion between the anterior and posterior chest wall along the left 4 th intercostal space The central aortic pressure should be recorded and compared with the cuff measured brachial pressure. If there is considerable difference between the two, subclavian artery stenosis should be in the differential The catheter should then be filled with 3-4 cc of contrast and advanced to engage the coronary ostium , in the LAO projection After ensuring that there is no ventricularization or damping of the pressure, a 2 to 3 cc of contrast should be injected to confirm the position of the catheter in the coronary ostium The overall risk of major complications with coronary angiography is 1-2%. This includes death, myocardial infarction, stroke, bleeding, vascular complications and contrast reaction. Technique

47. Standard Angiographic Views An easy way to identify the tomographic views is to use the anatomic landmarks - catheter in the descending aorta, spine and the diaphragm. The rough rules are: RAO vs. LAO - If the spine and the catheter are to the right of the image, it is LAO and vice versa. If central, it is likely a PA view Cranial vs. caudal - If diaphragm shadow can be seen on the image, it is likely cranial view, if not, it is caudal Catheter and spine to the LEFT RAO view No diaphragm shadow Caudal view Catheter at the CENTER PA view No diaphragm shadow Caudal view Spine to the RIGHT LAO view Diaphragm shadow Cranial view

48. Standard Angiographic Views LAO-Caudal view : 40 to 60 LAO and 10 to 30 caudal Best for visualizing left main, proximal LAD and proximal LCx RAO-Caudal view : 10 to 20 RAO and 15 to 20 caudal Best for visualizing left main bifurcation, proximal LAD and the proximal to mid LCx Shallow RAO-Cranial view : 0 to 10 RAO and 25 to 40 cranial Best for visualizing mid and distal LAD and the distal LCx (LPDA and LPL) Separates out the septals from the diagonals LAO-Cranial view : 30 to 60 LAO and 15 to 30 cranial Best for visualizing mid and distal LAD, and the distal LCx in a left dominant system Separates out the septals from the diagonals Left Coronary Artery

49. Standard Angiographic Views PA projection : 0 lateral and 0 cranio-caudal Best for visualizing ostium of the left main PA-Caudal view : 0 lateral and 20 to 30 caudal Best for visualizing distal left main bifurcation as well as the proximal LAD and the proximal to mid LCx PA-Cranial view : 0 lateral and 30 cranial Best for visualizing proximal and mid LAD Left lateral view : Best for visualizing proximal LCx, proximal and distal LAD Also good for visualizing LIMA to LAD anastomotic site Left Coronary Artery (other views)

50. Standard Angiographic Views Left Coronary Artery RAO 20 Caudal 20 LM LAD Diagonal Septals Distal LAD LCx RAO 20 Caudal 20 Knowledge of the orientation of the artery for a given view can help identify the probable path of the artery in the setting of complete occlusion Distal LAD fills by collaterals LAD Best for visualization of LM bifurcation and proximal LAD and LCx

51. Standard Angiographic Views Left Coronary Artery LAO 50 Cranial 30 LM LAD Diagonal Septals Distal LAD LCx PA 0 Cranial 30 LM LAD Diagonal Septals Distal LAD LCx Best for visualization of LM proximal and mid LAD Best for visualization of proximal and mid LAD and splaying of the septals from the diagonals. Also ideal for visualization of distal LCx

52. Standard Angiographic Views Left Coronary Artery PA0 Caudal 30 LM LAD Diagonal Septals Distal LAD LCx LAO 50 Caudal 30 OM LM LAD Diagonal Distal LAD LCx OM ‘Spider’ view Best for visualization of LM bifurcation and proximal LAD and LCx Best for visualization of LM bifurcation, proximal LAD and LCx and OM

53. Standard Angiographic Views LAO 30 : 30 LAO Best for visualizing ostial and proximal RCA RAO 30 : 30 RAO Best for visualizing mid RCA and PDA PA Cranial : PA and 30 cranial Best for visualizing distal RCA bifurcation and the PDA Right Coronary Artery

54. Standard Angiographic Views Right Coronary Artery LAO 30 Proximal RCA PDA Distal RCA Mid RCA RAO 30 Mid RCA PDA/PLV PA 0 Cranial 30 Proximal RCA PDA Distal RCA Mid RCA Best for visualization of ostial and proximal RCA Best for visualization of mid RCA and PDA Best for visualization of distal RCA and its bifurcation

55. Optimal angiographic views for coronary segments Carlo Di Mario, Nilesh Sutaria . CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976. There is no single magical projection that can be applied uniformly to all patients for visualizing a particular coronary atery

56. Panoramic coronary angiography GIORGIO TOMMASINI et al. Panoramic Coronary Angiography. JACC 31(4),March 15, 1998:871–7

57. Pitfalls of CAG – A Lumenogram