Coronary angiography

Coronary angiography

1. Coronary Angiography Raja Lahiri

2. Introduction Angiography: Visualisation of the vascular bed via X-ray/MRI with contrast injection Conventional CT MRA Conventional CAG: Current gold standard

3. History

4. History Initial attempts focussed on non selective contrast injections in aortic root Selective injections feared with risk of ventricular fibrillation based on animal studies Transient cardiac arrest with aortic occlusion with balloon was used to obtain better quality images 1958: Accidental injection of contrast in right coronary artery by Dr. Mason Sones and his associate Dr. F. Mason Sones

5. History First Coronary Angiogram(RCA) by Mason Sones First aortocoronary saphenous vein graft inserted by Rene Favaloro in May 1967

6. Indications Established CAD: To define coronary anatomy and formulate management plan Emergent revascularisation in STEMI To confirm non invasive diagnosis of CAD Left ventricular dysfunction, ventricular arrhythmias, ambiguous non invasive test results, out of hospital cardiac arrest survivors Pre Surgical evaluation

7. Contraindications No absolute contraindication Anemia Renal dysfunction Active infection High bleeding risk Contrast Allergy

8. EQUIPMENTS

9. Cardiac catheterisation laboratory

10. Coronary angiography catheters

11. Contrast material High osmolality ionic contrast media: Not used nowadays High incidence of adverse events Low osmolar non ionic contrast agents: Most commonly used agent Well tolerated Iso osmolar non ionic contrast agents

12. Access sites

13. Femoral Most frequently used access site Ease of access, lesser contrast and radiation exposure, freedom to upgrade to bigger size sheaths Need for immobilisation, local site complications: main drawbacks

14. Femoral

15. Access technique

16. Radial No need for immobilisation Lower rate of local vascular complications Increasingly being used as primary access site Slightly higher contrast and radiation exposure with beginners Spasm, loops, failure to get access may require switch to femoral route

17. Radial access tools

18. Radial access

19. Access sites (Other) Brachial Ulnar Radial in anatomical snuffbox

20. Angiography techniques Prior heparinisation Hemodynamic monitoring (Utmost important) Always check for pressure damping/ ventricularisation before injection Beware of air and clots

21. Contrast Injection Left coronary artery: 6-8ml over 2-3 seconds Right coronary artery: 4-6ml over 2-3 seconds Should be adequate to fill the coronary artery completely without streaming Excessive contrast injection should be avoided Cine acquisition (@10fps) should continue till contrast clears from the system

22. Angiographic projections

23. Angiographic views of the left coronary artery

24. Angiographic views of the right coronary artery

25. Angiographic projections

26. Left coronary artery angiogram

27. LMCA Best seen in a shallow LAO projection with slight caudal angulation Cranial angulation to improve visualization of its proximal and ostial segments. Steep LAO caudal (also called the spider view) lays out the terminal left main bifurcation. Not helpful in the case of a horizontally positioned heart, in which situation a steep RAO caudal view is substituted.

28. LAD No single view adequately depicts the entire course of the LAD. The proximal LAD is best visualized in steep LAO projections with cranial angulation , whereas the middle and distal segments are better seen in LAO and RAO views with some caudal angulation . The best view for most of the diagonal arteries, to include their origin and distal segments, is usually a steep LAO (50 degrees) with steep cranial (50 degrees) angulation

29. LCX The LCX is best seen in caudal projections. The proximal portion of the LCX is usually imaged in the RAO caudal angulation , which also lays out the marginal arteries. An alternative view for the mid segment of the LCX and the marginal arteries is the steep LAO caudal (spider) view.

30. Right coronary artery angiogram

31. RCA The proximal segment of the RCA is best seen in the flat LAO angulation . For optimal visualization of the ostium , a steep (50 degrees) LAO projection is preferred. The mid segment of the RCA is best seen in the LAO and flat RAO projections. The crux, or distal RCA, and the proximal portions of the right PDA and PLB arteries are best seen with an AP or slight LAO projection with 20 to 30 degrees of cranial angulation . The middle and distal segments of the right PDA are best visualized with a flat RAO projection.

32. Standard Angiographic views

33. 5 views of Left coronary artery

34. 2 views of Right coronary artery

35. Description of coronary angiograms

36. Stenosis

37. Calcification

38. Thrombus

39. Tortuousity

40. Dissection

41. Myocardial bridge

42. Flow TIMI grade: TIMI 0 flow (no perfusion) refers to the absence of any antegrade flow beyond a coronary occlusion. TIMI 1 flow (penetration without perfusion) is faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed. TIMI 2 flow (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of the distal territory. TIMI 3 is normal flow which fills the distal coronary bed completely

43. Dominance Right Dominance Left Dominance Co- Dominance

44. Coronary anomalies Anomalous origin From same sinus From different sinus From other coronary artery Single coronary Aneurysms Coronary fistulas

45. Coronary anomalies

46. Coronary aneurysms

47. Graft Angiography JR4: Most commonly used for various grafts Amplatz right, LIMA catheter, dedicated bypass graft catheters may be needed Clips at sites of graft may be useful guides Prior CTA gives valuable information Root angio with pigtail to identify grafts

48. Graft Angiography

49. LIMA Angiography

50. LV angiography Not routine nowadays Pigtail with contrast injection via power injector Done in RAO 30 to estimate LV function and mitral regurgitation Assessment of LVEDP and LV to aorta gradient

51. LV Angiography

52. Complications Local: Bleeding Hematoma Infection Pseudoaneurysm Compartment Syndrome Coronary Dissection, embolism, spasm

53. Complications Contrast related Contrast nephropathy Allergic reactions CHF Arrhythmias Access vessel dissection Stroke Death

54. Other coronary imaging modalities CTA MRA IVUS OCT (Optical Coherence Tomography) Angioscopy

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