coronaryangiography-220330142539 (1).pdf

Cag

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

3. ANATOMY OF CORONARIES

4. Clinical division of RCA
•Proximal -Ostiumto 1st main RV branch
•Mid -1st RV branch to acute marginal branch
•Distal -acute margin to crux

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

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

7. 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

8. Dominance
•Right-Dominant Circulation-85%
–RCA
•conusbranch (supplies RVOT)
•AM(supply free wall of RV)
•AV nodal artery, PDA-PLV (supplies infpart 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

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

10. Coronary Segment Classification

11. Angiographic Views-Nomenclature
•AP position : Image intensifier is directly over patient
with beam travelingperpendicularly 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 :Imageintensifier is tilted toward head of
patient
•Caudal : Image intensifier is tilted toward feet of
patient

13. Standard Angiographic Views
An easy way to identify the tomographicviews 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 CENTERPA view
No diaphragm
shadow
Caudal
view
Spine to
the
RIGHTLAO view
Diaphragm
shadow
Cranial view

15. LCA-AP caudal or shallow RAO
•LMCA -entire length
•ProxLAD & LCX (branches overlapped)
•After LM segment, slight RAO or LAO
Angulationmay be necessary to clear density
of vertebrae /catheter shaft

16. 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 angulationpermits view of LAD/LCX bifurcation
•LAO-cranial angulationthat is too steep or inspiration
that is too shallow produces considerable overlapping
with diaphragm and liver, degrading the image

17. LAO Cranial

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

19. RAO caudal

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

21. RAO cranial

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

23. LAO caudal

24. 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

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

26. LAO cranial

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

28. RAO VIEW

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

30. AP cranial

31. Lateral view
•Shows RCA origin (especially in pt with more
anteriorlyoriented orifices) and mid RCA
•PDA and PL are foreshortened

32. Saphenousvein graft views
•RCA graft—LAO cranial, RAO, and AP cranial
•LAD graft (or internal mammary artery)—
lateral,RAOcranial, LAO cranial, and AP
(lateral view is especially useful to visualize
anastomosisto LAD)
•LCX (and obtuse marginal branches) grafts—
LAO caudal and RAO caudal
•Diagonal graft—LAO cranial and RAO cranial

34. DUAL OSTIA

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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
PDADistal
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

42. 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

43. ACC/AHA Lesion Classification

45. 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

48. 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 ≤ 682.5
> 68 2
100 1
100 0
Infarct-Related
Artery
Correction Factor
LAD 1.7
SVG 1.6
RCA 1.0
LCx 1.0

49. Clinical syntax scoring

51. Rentropcollateral circulation

53. Thank You!