How to read coronary angiography

Simple approach to interpret coronary angiography views.
Youtube lecture link:
https://youtu.be/Xb8BSJsSJq4

1. Ahmed Elborae How to ? series How to read coronary angiography?

2. First read history… When these countries meet outside a world war

3. Here we begin ….. Catheterised The IVC of cadaver "...I found the task so truly arduous... that I was almost tempted to think... that the movement of the heart was only to be comprehended by God. For I could neither rightly perceive at first when the systole and when the diastole took place by reason of the rapidity of the movement... “ W. Harvey1651

4. A. Chauveau& E.J. Marey 1863 Introduced a catheter via the IJV into RV&RA and recorded intracardiac pressure

5. First in living human ! Werner Forssmann 1929 Forssmann cut down his own left arm vein and introduced the ureteral catheter for about 60 cm, then did CXR Noble prize 1956

6. First selective coronary angiography Mason Sones 1956 A catheter used for a supravalvular aortic injection accidentally slipped into the proximal right coronary artery

7. First coronary balloon angioplasty Andreas Gruentzig 1977 The patient The assistant 1 st balloon angioplasty for a 38-year-old gentleman with proximal LAD lesion

8. Does it need special skills?

9. Simply it is eye exercise

10. Be familiar with coronary anatomy

11. Thanks god , I am a cardiologist ! Cerebral angiography

12. Corona = Crown “Latin” AV groove IVS groove AV groove LCX LAD RCA RV L V LMT

13. Be minded with the 3D orientation

14. Angiographic views A combination of 2 directions of rotation 1ST 2nd LAO-Cranial 40-30 : Means Left 40 and Cranial 30

15. Left cranial 40,25 Right caudal 30,30 AP caudal 8,30 Left caudal “Spider” 40,25 Lateral 90,0 For simplification - Rt and AP caudal are quiet similar - Rt and AP cranial are quiet similar 1 3 4 Right cranial 30,30 AP cranial 8,30 2 Left system views -Caudal views> Better for LCX-LMT -Cranial views> Better mid/distal LAD

16. How to differentiate views AP-cranial view Yes Yes No No Step 1 Step 2 Step 3 Yes No LCX follow the view, Cranial= LCX is the upper one

17. How to differentiate views Right caudal view Yes Yes No No Step 1 Step 2 Step 3 Yes No LCX follow the view, Caudal= LCX is the lower one

18. Understand an memorize the following 4 Views Or

19. Understanding right and AP caudal views Courtesy of AV groove AV groove LCX LAD

20. Courtesy of Understanding right and AP cranial views IVS groove IVS groove LCX LAD

21. Understanding left cranial view Courtesy of IVS groove IVS groove AV groove LCX LAD

22. Understanding left caudal view “Spider” Courtesy of AV +IVS groove AV groove IVS groove LCX LAD

23. Understanding lateral view Courtesy of AV groove IVS groove

24. Right caudal 30,30 Right cranial 30,30 Left cranial 40,25 Left caudal 35,25 Just memorize these four pictures

25. RCA is much more easy Left cranial view Lateral view AP cranial view PDA PL

26. How to name coronary segments

27. Proximal Mid Distal Proximal Distal Proximal Mid Distal Prox. >Till 1 st septal Mid> till the curve Distal > thereafter Prox. >Till 1 st OM Distal > thereafter Prox. >Till 1 st curve Mid> till the 2 nd curve Distal > thereafter Related to branches or bends

28. How to determine dominance

29. Which one supply the posterior septum “Gives PDA” RCA 85% LCX 8% Co-dominant 7 %

30. Best seen in the left cranial view Non-dominant Lcx Dominant Lcx

31. How to assess lesion severity Significant? Not significant?

32. Compare lesion to surrounding ”Reference vessel”

33. Grading of lesion severity

34. Two orthogonal views Courtesy of E.Brilakis Eccentric lesions

35. Quantitative coronary angiography QCA Courtesy of E.Brilakis

36. Fractional flow reserve FFR < 0.8 Significant

37. Fractional flow reserve FFR only 35% of angiographic (50–70%) stenosis were significant by FFR 80% of angiographic (71–90%) stenosis were significant by FFR 96% of angiographic stenosis ≥ 90 %were significant by FFR “FAME trial”

38. ESC revascularization guidelines 2018

39. Intravascular imaging “Your third eye!” IVUS OCT

40. How to assess coronary flow

41. TIMI flow What is TIMI? : T hrombolysis I n M yocardial I nfarction A series of trials assessing thrombolysis success by coronary flow grading before 1ry PCI era

42. Actually microcirculation what really matters !

43. Myocardial blush

44. MBG 0 MBG 3 Myocardial blush

45. Special type of lesions

46. Thrombotic lesion Different treatment strategy if heavy burden (4,5) “Aspiration catheters-GP2b3a”

47. Calcified lesion LAO caudal ”spider view” Lateral view Calcified LMT-LAD is seen in two orthogonal views “No contrast needed”

48. Different treatment strategy “ Rotablation ”

49. In-stent lesion Different treatment strategy “Drug coated balloons”

50. CTO lesion Different treatment strategy “Special wires, microcatheters, and expertise”

51. Scores to plan

52. 1- Which circulation is dominant? 2-Choose diseased segments 3-Describe the lesion (CTO, bifurcation, tortuous, calcified, long, thrombotic , distal diffuse disease)

53. When to calculate?

54. Know the basic tools Dr Melvin Judkin , 1968

55. Guide Wire+ balloon Stent

56. Further reading Download link A good start

57. Further reading Download link A good start

58. Course link A course that put me on the track !

59. Best YouTube learning channel and book Channel link

60. Take home message

61. Right caudal 30,30 Right cranial 30,30 Left cranial 40,25 Left caudal 35,25 Just memorize these four pictures

62. Thank You