Radiological anatomy of coronary artery and its variations copy copy.pptx

This presentation explores the radiological anatomy of the coronary arteries through various imaging modalities, including CT coronary angiography and conventional angiography. It details the normal course, origin, and branching patterns of the major coronary arteries—right coronary artery (RCA), left main coronary artery (LMCA), left anterior descending (LAD), and left circumflex artery (LCx)—along with common anatomical variants. Designed to aid radiology residents, cardiology trainees, and medical professionals in understanding and identifying coronary artery anatomy for accurate interpretation and clinical decision-making.

1. Moderator: Dr. Vinodh Presentor : Dr. Sandeep Kumar. S Radiological anatomy of coronary artery and its variations.

2. The heart is supplied by two coronary arteries, arising from the ascending aorta. Both arteries run in the coronary sulcus.

3. Features of Coronary Arteries- i. The blood flows through these arteries during diastole of heart. ii. Diameter is 1.5–5.2 mm. iii. Left coronary is larger in caliber and supplies more myocardium. iv. These arteries are ‘functional end arteries'. Though their branches anastomose with each other but one cannot compensate for the other artery in case of thrombosis.

4. CORONARY CUSP- There are three cusps of the aortic valve: The non-coronary cusp, which contains no ostia . The right coronary cusp, which contains the ostia of the right coronary artery, and the Left coronary cusp, which contains the ostia of the left (main) coronary artery.

5. The Society of Cardiovascular Computed Tomography: Coronary Segments

6. CORONARY ARTERIAL DOMINANCE-

7. Coronary arterial dominance  is defined by the vessel which gives rise to the posterior descending artery(PDA).which supplies the myocardium of the inferior third of the  interventricular septum. Most hearts (80-85%) are  right dominant  where the PDA is supplied by the right coronary artery(RCA). The remaining 15-20% of hearts are roughly equally divided between  left dominant  (~10%) and  codominant   (~20%). 

8. IMAGING MODALITIES

9. Coronary Imaging Technique INVASIVE PROCEDURE : CATHETER CORONARY ANGIOGRAPHY INVASIVE ULTRASOUND NON INVASIVE PROCEDURE : CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY ELECTRON BEAM СТ ( EB) MULTIDETECTOR CT (MDCT) 2. MAGNETIC RESONANCE IMAGING 3. NUCLEAR IMAGING.

10. CATHETER ANGIOGRAPHY A minimally invasive procedure to access coronary circulation and blood filled chambers of the heart us ing a c atheter . The technique was first performed by Dr. Mason Sones at the Cleveland Clinic in 1958. The major epicardial vessels and their 2 & 3" order branches can be visualized using coronary angiography. It is performed for both diagnostic and interventional (treatment) purposes.

11. PROCEDURE PROPER PATIENT PREPARATION: 1. Arrives at Cath. Lab at morning with at least 6 hrs fast. 2. Allowed to take all medications as advised by physician including aspirin except oral hypoglycemic agents. 3.Intravenous access is secured. 4. Sedation with benzodiazipine is recommended. Vascular Access: Seldinger Technique is used, transfemoral route is MC ( transradial & transbrachial routes can also be used)

12. 6. Contrast media-Low osmolarity , Non-ionic 7. Dose-3-10 ml;320-370 mg of iodine/m l , using a hand-held syringe filled from a reservoir. 8. Left coronary artery is filled with 6-8 ml, right coronary artery is filled with 3-5 ml usually

13. CATH LAB

14. Left Coronary Angiogram

15. Right Coronary Angiogram

16. Pitfalls of coronary angiography Inadequate vessel o pacification- May give impression of ostial stenoses, missing side branches or thrombus. Eccentric stenosis- Coronary atherosclerosis often leads to eccentric or slit-like narrowing than central narrowing; so if the long axis of the vessel is projected, the vessel may appear to have a normal or near normal caliber. Superimposition of branches. Foreshortening of the stenotic segment due to projectional defect.

17. INVASIVE ULTRASOUND

18. CATHETER DESIGNS: Miniaturized transducer and a console* 3.6 to 3.2 French in size 6 Fr guide catheters Operate at 30- 45MHz Piezoelectric transducer at 1800rpm

19. EXAMINATION TECHNIQUE . Standard guide catheter under full anticoagulation Intracoronary infusion of nitroglycerine Through 0.0014-in guidewire Advanced under fluoroscopic guidance Approx 10mm distal to the segment of interest w ithdraw the catheter at a constant speed Up to aortic coronary junction

20. PITFALLS Similar appearance of different materials NURD (Non-uniform rotational distortion) Tortuosity Severely stenotic segments Small guide lumen size Slack in the catheter shaft Side lobe artifact Reverberation

21. CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY.

22. Coronary computed tomography angiography (CC is an effective noninvasive method to image the coronary arteries. PATIENT PREPARATION Avoid caffeine and smoking 12 hours prior to the procedure to avoid cardiac stimulation. B eta - blocker: Oral or I.V B eta -blocker is used in patient with heart rate greater than 60 bpm Oral 50- 100 mg metaprolol administered 45 min to 1 hr before procedure. Or I.V Metaprolol 5 to 20 mg at the time of procedure Sublingual Nitrates or Nitroglycerine: given immediately before the procedure to dilated the coronary arteries.

23. Patient Positioning and Preparation for Scanning Patients are positioned on the CT examination table in the supine position ECG leads are attached to obtain an adequate ECG tracing. a)Prospective ECG gating b)Retrospective ECG gating Intravenous access via a large intravenous line (18 gauge cannula) is necessary to ensure easy injection of the viscous contrast agent at a flow rate of 5 mL/s Training of patients with repeated breath holds Topogram : begin above carina and end 2cm below diaphragm. The iodine medium concentration - (300-400mg iodine/ ml is used)

24. Left coronary (LC), right coronary (RC) and posterior non-coronary (NC) cusp

25. LCA divides into LAD and Cx

26. TYPES OF LAD- type I: short vessel (can terminate before apex) type II: intermediate vessel type III: long wrap-around vessel (around the apex)

27. CORONARY MAGNETIC RESONANCE ANGIOGRAPHY First choice in evaluation of proximal coronary pathology in young and in particular if associated congenital anomalies are present The limitations for imaging the distal coronary arterial segments remain The use of contrast agents improve the signal-to-noise ratio in these distal coronary branches In future with the advent of shorter scan times better post processing software -the diagnostic accuracy of 3D, navigator-echo MR angiography will increase

28. Congenital variation of coronary anatomy Angelini has suggested classifying coronary anomalies into three categories: Abnormalities of the coronary ostia : a) High Take off b) Multiple ostia c) Single coronary artery d) Anomalous origin of coronary artery from pulmonary trunk e) Origin of coronary artery or branch from opposite or non-coronary cusp with abnormal course

29. 2 . Anomalous course: Myocardial bridging b) Duplication of arteries 3. Anomalies of termination: Coronary artery fistula b) Coronary arcade c) Extra cardiac termination

30. High Take off

31. Multiple ostia

32. Coronary anomalies Benign or Minor Coronary Anomalies Left Cx artery arising from right aortic sinus - Most common Independent origin of LAD artery and Cx from the left aortic sinus -The absence of LMCA is the common anomaly of the left coronary vessel system.

33. B. Malignant or major coronary Anomalies RCA arising from left coronary sinus: Most common malignant coronary anomaly. Present in 20—25% of cases. RCA has inter-arterial course and prone for compression

34. 2. LMCA arising from right aortic sinus : LMCA courses between aorta and pulmonary artery. 60% die before are 20 during strenuous exercise.

35. 3. Anomalous origin of LMCA, LAD or RCA from the pulmonary trunk: Anomalous origin of LMCA is called Blant -White-Garland syndrome, whereas if anomalous origin of RCA is called reverse Blant -White-Garland syndrome.

36. Origin of coronary artery or branch from opposite or non-coronary cusp with abnormal course

37. Myocardial bridging: Epicardial segment of a coronary artery tunnels through a portion of myocardium. Involves middle segment of LAD. Superficial - < 2mm depth Deep - > 2mm depth

38. Coronary Artery fistula: Communication between one or two coronary arteries and a cardiac chamber or systemic vein. Large AV communication produce myocardial perfusion deficit

39. Atresia of coronary ostium : It can happen that coronary arteries become obstructed or totally occluded in fetal or neonatal life due to a coronary ostial hypoplasia or atresia. In this case, the distal coronary bed is supplied by collateral circulation from the opposite side.

40. Duplication

41. Short LMCA < 5 mm Long LMCA > 15 mm

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