CORONARY ANGIOGRAPHY.pptx

Reading angiograms, angiogram interpretation, LAD, RCA, Lesion, classification

1. Coronary angiography and angiographic views - Dr. Rohit Walse Intervention Fellow, SCTIMST, Kerala

2. ANATOMY OF CORONARIES

3. Clinical division of RCA Proximal - Ostium to 1st main RV branch Mid - 1st RV branch to acute marginal branch Distal - acute margin to crux

4. Clinical division of LAD Proximal - Ostium to 1st major septal perforator Mid - 1st perforator to D2 (90 degree angle) Distal - D2 to end

5. Clinical division of the LCX Proximal - Ostium to 1st major obtuse marginal branch Mid - OM1 to OM2 Distal - OM2 to end

6. Normal calibre LMCA : 4.5 ± 0.5 mm LAD: 3.7 ± 0.4 mm LCX : 3.5 ± 0.5 mm ( 4.2 mm if dominant) RCA: 3.9 ± 0.6 mm ( 2.8 mm if non-dominant ) LCA ostium ~ 4mm RCA ostium ~ 3.2mm

7. Dominance Right-Dominant Circulation-85% RCA conus branch (supplies RVOT) AM(supply free wall of RV) AV nodal artery, PDA-PLV (supplies inf part of IVS ) Left-Dominant Circulation- 8%, PD,PLV & AV nodal all supplied by terminal portion of LCX Balanced-Dominant Circulation- 7% RCA- PD LCX- all PLV

8. What is significant CAD? >50% - significant disease >2 mm vessel only considered for revscularisation >70% considered hemodynamically significant ds >50% is considered in LMCA

9. Coronary Segment Classification

10. Angiographic Views-Nomenclature AP position : Image intensifier is directly over patient with beam traveling perpendicularly back to front (i.e., from posterior to anterior) to patient lying flat on x-ray table RAO position : Image intensifier is on right side of patient. A, anterior; O, oblique LAO position: Image intensifier is on left side of patient Lt Lateral position :Image intensifier rotated 90 deg parallel to floor Cranial : Image intensifier is tilted toward head of patient Caudal : Image intensifier is tilted toward feet of patient

11. 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

12. LCA - AP caudal or shallow RAO LMCA -entire length Prox LAD & LCX ( branches overlapped) After LM segment, slight RAO or LAO Angulation may be necessary to clear density of vertebrae /catheter shaft

13. LAO-cranial view LMCA (slightly foreshortened) LAD- Septal & diagonal are separated clearly LCX/OM : foreshortened / overlapped PD/PL of left-dominant circulation are displayed clearly Deep inspiration helpful Cranial angulation permits view of LAD/LCX bifurcation LAO-cranial angulation that is too steep or inspiration that is too shallow produces considerable overlapping with diaphragm and liver , degrading the image

14. LAO Cranial

15. RAO-caudal LMCA bifurcation Origin & course of LCX/OM , RI & prox LAD seen clearly One of the best for visualization of LCX LAD beyond proximal segment obscured Apical LAD displayed clearly

16. RAO caudal

17. RAO-cranial Used for origins of diagonals along mid / distal LAD Diagonals bifurcations well visualized Diagonals projected upward Prox LAD/LCX usually overlapped

18. RAO cranial

19. LAO-caudal (“spider” view) LMCA (foreshortened) & LMCA bifurcation Prox & mid LCX with origins of OM

20. LAO caudal

21. Lateral view Best view to show mid & distal LAD LAD/LCX well separated Diagonals usually overlapped RI course well visualized It best shows insertions of bypass grafts into mid LAD

22. RCA --- LAO-cranial Origin of RCA Entire length of mid RCA PDA bifurcation (crux ) Cranial angulation tilts PDA down to see vessel contour / reduce foreshortening Deep inspiration is necessary to clear diaphragm

23. LAO cranial

24. RCA - RAO view Shows mid RCA & length of PDA / PL Septals coursing upward from PDA, supplying occluded LAD artery via collaterals , may be clearly identified PL are overlapped, may need addition of cranial view

25. RAO VIEW

26. AP cranial Shows origin of RCA Mid segment foreshortened Best view for PD/PL of dominant RCA system and size of collateralized LAD

27. AP cranial

28. Lateral view Shows RCA origin ( especially in pt with more anteriorly oriented orifices ) and mid RCA PDA and PL are foreshortened

29. Saphenous vein graft views RCA graft—LAO cranial, RAO, and AP cranial LAD graft (or internal mammary artery)— lateral,RAO cranial, LAO cranial, and AP (lateral view is especially useful to visualize anastomosis to LAD) LCX (and obtuse marginal branches) grafts—LAO caudal and RAO caudal Diagonal graft—LAO cranial and RAO cranial

30. DUAL OSTIA

31. Coronary Anomalies Increased risk of sudden death Anomalous LCA from right sinus - Inter-arterial Course Anomalous LCA from right sinus - Retro-aortic course Prognosis benign AORTA PULMONARY ARTERY AORTA PULMONARY ARTERY RCA RCA LM LM LAD LAD LCX LCX

32. Coronary Anomalies Prognosis benign Anomalous LCx from right cusp Anomalous RCA from left cusp LM RCA LAD Prognosis benign Left coronary artery arising from the right sinus of Valsalva - course relative to great vessels must be defined as interarterial course portends an increased risk of sudden death

33. Coronary Aneursym Coronary Aneurysm: Vessel diameter > 1.5x neighboring segment Incidence : 0.15%-4.9%; very rare in LMCA Etiology : mainly atherosclerosis; other causes include Kawasaki’s, PCI, inflammatory disease, trauma, connective tissue disease

34. 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

35. 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

36. 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

37. 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

38. Angiogram-Interpretation A systematic interpretation of a coronary angiogram would involve: Evaluation of the extent and severity of coronary calcification just prior to or soon after contrast opacification Lesion quantification in at least 2 orthogonal views: Severity Calcification Presence of ulceration/thrombus Degree of tortuosity ACC/AHA lesion classification Reference vessel size Grading TIMI flow Grading TIMI myocardial perfusion blush grade Identifying and quantifying coronary collaterals

39. ACC/AHA Lesion Classification

40. Other Definitions Lesion length: Measured “shoulder-to-shoulder” in an unforeshortened view Discrete Lesion length < 10 mm Tubular Lesion length 10–20 mm Diffuse Lesion length ≥ 20 mm Lesion angulation: Vessel angle formed by the centerline through the lumen proximal to the stenosis and extending beyond it and a second centerline in the straight portion of the artery distal to the stenosis Moderate: Lesion angulation ≥ 45 degrees Severe: Lesion angulation ≥ 90 degrees Calcification: Readily apparent densities noted within the apparent vascular wall at the site of the stenosis Moderate: Densities noted only with cardiac motion prior to contrast injection Severe: Radiopacities noted without cardiac motion prior to contrast injection

41. TIMI Frame count Type of Frame Count How to perform Result Unadjusted Frame Count Subtract initial frame from final frame number  Unadjusted Frame Count = 28 - 8 = 20 20 Raw TIMI Frame Count Adjust for filming speed.  Raw TIMI Frame Count = 20 * (30 fps)/(15 fps) = 40 40 Corrected TIMI Frame Count Correct for vessel length.  Corrected TIMI Frame Count = 40 ÷ (1.6) = 25 25 Raw TFC TIMI Flow Grade ≤ 40 3 > 40 and ≤ 68 2.5 > 68 2 100 1 100 Infarct-Related Artery Correction Factor LAD 1.7 SVG 1.6 RCA 1.0 LCx 1.0

42. Clinical syntax scoring

43. Rentrop collateral circulation

44. Thank You!