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
1st 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
LV
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
Diaphragm
seen
Cranial Caudal
Catheter
to left
Right/AP Left
Vertebral column+
Horizontal ribs
AP Right
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
Diaphragm
seen
Cranial Caudal
Catheter
to left
Right/AP Left
Vertebral column+
Horizontal ribs
AP Right
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
LCX
LAD

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

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

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

23. Understanding lateral view
Courtesy of

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 1st septal
Mid> till the curve
Distal > thereafter
Prox. >Till 1st OM
Distal > thereafter
Prox. >Till 1st curve
Mid> till the 2nd 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? : Thrombolysis In Myocardial Infarction
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