for beginners it may help

1. BASICS OF CORONARY ARTERY
ANATOMY AND ANGIOGRAPHIC
VIEWS
DR BIPUL ROY
PDT(1ST YEAR)
DEPT OF CARDIOLOGY
MEDICAL COLLEGE & HOSPITAL (KOLKATA)

2. TOPICS TO BE DISCUSSED
• NORMAL CORONARY ARTERY ANATOMY
• UNDERSTAND DIFFERENT ANGIOGRAPHY VIEWS
• HOW TO OPTIMIZE IMAGE

3. AORTIC SINUSES
• anatomic spaces at the
aortic root
• bounded internally by the
aortic valve leaflets and
externally by outward
bulges of the aortic wall
• 3 in numbers
• right coronary or anterior
• left coronary or left
posterior
• noncoronary/posterior or
right posterior

4. Right Coronary Artery
• Origin -Right aortic sinus (lower origin than LCA)
• Course[Right-dominant system (85%)]
• proximal courses superiorly and rightward, posterior to
the pulmonary trunk
• curves in an inferior direction in the plane of the
atrioventricular groove
• distal segment curves toward the cardiac crux as
it(travels along the posterior interventricular groove)
• subsequent bifurcation forming the posterior left
ventricular branch and the posterior descending artery
(PDA)

6. BRANCHES
• Conus Artery
• ~50% have a separate origin(3rd coronary artery)
• Courses anteriorly and upward over the RVOT
• May be an important source of collaterals
• SA Nodal Artery
• Usually 2nd branch of RCA
• Courses obliquely backward through upper portion of atrial septum
• anteromedial wall of the RA

7. BRANCHES OF RCA
• Right Ventricular (Acute Marginal Branches)
• Arise from mid RCA; Supply anterior RV
• May be a collateral source
• AV Nodal Artery
• Arises at or near crux; Supplies AV node
• Posterior Descending Artery (PDA)
• Supplies inferior wall, ventricular septum, posteromedial papillary muscle
• Posterolateral Artery (PL)
• From crux to left AV groove ➔ Meet LCx artery

8. CORONARY ARTERIAL DOMINANCE
• right coronary artery gives rise to the PDA and at least
one posterolateral branch -right dominant circulation
(85% )
• RCA gives rise to PDA and LCX provides all
posterolateral branches - co-dominant circulation (7.5%)
• left dominant circulation (7.5%)-left circumflex artery
continues as the PDA and provides poterolateral
branches

9. Left Main Coronary Artery
• Origin-Upper portion of the left aortic sinus just
below the sinotubular ridge.
• Typically about 10 to 15 mm in length
• 3 to 6 mm diameter

10. LEFT ANERIOR DESCENDING ARTERY
• Courses along epicardial surface of anterior
interventricular groove toward cardiac apex
• LAD Supplies- 45~55% of LV; anterolateral, apex, and
septum
Types
• type I: terminate before apex
• type II: reaches upto apex
• type III: long wrap-around vessel (around the apex)

11. BRANCHES OF LAD
-Septals-
root-like, arise at 90-degree angle approximately,
intramyocardial, less movement
-Diagonals- supply lateral LV, anterolateral
papillary muscles also

12. Left Circumflex Artery
Course-Down distal left AV groove
Left-dominant system (7.5%) -supply PL, PDA and AV nodal
arteries
Balanced system (7.5%)-PDA from RCA, PL from LCx
Branches
Obtuse marginal; lateral free wall of LV
SA nodal branch -40%
LV Supplies
- 15~25% of LV
40~50% in dominant LCx system

13. ANGIOGRAPHY VIEW

14. The components of an X-ray system. The system consists of the X-ray
source, the X-ray image detector (image intensifier or flat-panel
detectors), the digital video processor, and the display monitor.

15. Cine frame from the first selective coronary arteriogram
taken by F. Mason Sones, MD, on October 30, 1958

16. ROTATION VS ANGULATION
• orientation of the X-ray tube with respect to the
patient is described using two angles
• “rotation”- position of the image intensifier around the longitudinal axis of
the patient. Zero degrees is vertically , positive angles are towards the
patient's left and negative angles are towards the patient's right
• “angulation”-describes the position of the image intensifier in the short axis
of the patient (this axis can be imagined as a line joining both shoulders).
Zero degrees is directly above the patient's head, positive angles are towards
the patient's head (cranial ), negative angles are towards the patient's legs
(caudal

19. ANGIOGRAPHIC VIEWS
• ANATOMICAL LANDMARKS FORMED BY THE
SPINE,CATHETER AND DIAPHRAGM PROVIDE INFORMATION
• IN LAO - SPINE SEEN ON RIGHT SIDE OF IMAGE
• IN RAO – CATHETER AND SPINE ARE FOUND ON LEFT
• PA IMAGING-CATHETER AND SPINE ARE IN CENTRE
• DIAPHRAGM HELP TO IDENTIFY ANGULATION- CAUDAL
ANGULATION NO DIAPHRAGMATIC SHADOW

20. no steadfast rules in which
tomographic views are most useful
• GENERALLY FOR CIRCUMFLEX AND PROXIMAL EPICARDIAL
VISUALIZATION - THE CAUDAL VIEWS ARE MORE USEFUL
• FOR LAD AND LAD/DIAGONAL BIFURCATION THE CRANIAL
VIEWS ARE USEFUL

21. Main coronary trunks lie in one of two orthogonal planes
Anterior descending and posterior descending coronary
arteries lie in plane of IVS
Right and circumflex coronary trunks lie in plane of AV
Valves
60 LAO projection is looking down plane of IVS, with
plane of AV valves seen en face
30°RAO projection, one is looking down plane of AV
valves, with plane of IVS seen en face

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

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

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

26. left coronary artery
• 1. RAO-caudal to visualize the left main, proximal LAD,
and proximal circumflex
• 2. RAO-cranial to visualize the mid and distal LAD without
overlap of septal or diagonal branches
• 3. LAO-cranial to visualize the mid and distal LAD in an
orthogonal projection
• 4. LAO-caudal to visualize the left main and proximal
circumflex
One or more supplemental views (PA, lateral-cranial, lateral caudal) may then
be taken to clarify any areas of uncertainty

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

28. LAO-CAUDAL
LMCA
(foreshortened)
LMCA
bifurcation
Prox &mid
LCXwith
origins of
OM seen
better

29. RAO-CAUDAL
LMCAbifurcation, Origin
&courseof
LCX/OM, RI &prox LAD
seen clearly
One of the best for
visualization of LCX
LAD beyond proximal
segment obscured
Apical LADdisplayed
clearly

30. RAO-CRANIAL
Used for origins of
diagonals along mid
/distal LAD
Diagonals bifurcations
well visualized
Diagonals projected
upward
Disadvantage-Prox
LAD/LCXusually
overlapped

31. PA-CAUDAL
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

32. Lateral view(left lateral)
Best view to show mid &
distal LAD,
LAD/LCX wellseparated,
Diagonals usually
overlapped
RI course wellvisualized
It best shows insertions
of bypass grafts into mid
LAD

34. right coronary artery screening views
• l. LAO to visualize the proximal and mid right coronary
artery (RCA)
• 2. LAO cranial to visualize the distal right coronary artery
and its bifurcation into the posterior descending and
posterolateral branches
• 3. RAO-cranial to visualize the posterior descending and
posterolateral branches
• 4. Lateral to visualize the mid-RCA

36. LAO CRANIAL
Origin of RCA,Entire length of
mid RCA
PDAbifurcation (crux)
Cranial angulation tilts PDAdown
to see vessel contour / reduce
foreshortening
Deep inspiration is necessary
to clear diaphragm

37. RAO VIEW
Shows RCAorigin
(especially in patient with
more anteriorly oriented
orifices) mid RCAseen better
PDA and PLare
foreshortened

38. PA-CRANIAL
Shows origin ofRCA Mid
segment foreshortened
Best view for PD/PL of
dominant RCAsystem and size
ofcollateralized LAD
LEFT-LATERAL
Shows RCAorigin (especially in
pt with more anteriorlyoriented
orifices) and mid RCA
PDA and PLare
foreshortened

39. LEFT CORONARY SYSTEM
Standard Views – 4 (4 corners)
1. LAO 40/Cranial 20 -LAD, Dx; LM ostium
2. LAO 40/Caudal 20 - prox LAD, prox LCx, distal LM
3. RAO 20/Caudal 20 -LM, prox/mid/disal LCx
4. RAO 10/Cranial 40 -prox/mid LAD
Supplemental Views
AP/Cranial 30-40 -LAD
AP/Caudal -LM, LCx
AP 0-20 caudal -LM

40. RIGHT CORONARY SYSTEM
• Standard Views - 2
• 1. LAO 40/Cranial 20 prox, mid RCA
• 2. RAO 30/Cranial 20 prox, mid RCA
• Supplemental Views
• AP/Cranial 30-40 distal RCA
• LAO 50/Cranial 30 distal RCA

41. Saphenous vein graft views
1. RCAgraft—LAO cranial, RAO, andAP cranial
2. LAD graft (or internal mammary artery)—lateral,
RAO cranial, LAO cranial, and AP (lateral view is
especially useful to visualize anastomosis to LAD)
3. CFX (and obtuse marginal branches) grafts—LAO
caudal and RAOcaudal
4. Diagonal graft—LAO cranial andRAO cranial

42. Angiographic CoronaryArtery Diameter by Location and Gender
Data from Dodge JT Jr, Brown BG, Bolson EL, et al. Lumen diameter of normal human coronary arteries; influence of age, sex, anatomic variation,
and left ventricular hypertrophy or dilation. Circulation . 1992;86:232-246; MacAlpin RN,AbbasiAS, Grollman JH, et al. Human coronary artery
size during life: a cinearteriographic study. Radiology . 1973;108:567-576; and Kimball BP, LiPreti V, Buis, et al. Comparison of proximal left
anterior descending and circumflex coronary artery dimensions in aortic valve stenosis and hypertrophic cardiomyopathy.Am J Cardiol.
1990;65:767-771..
Dodge et al MacAlpin et al Others
LMCA (mm) 4.5 ± 0.5 (men)
3.9 ± 0.4 (women)
4.3 ± 0.6 (men)
3.5 ± 0.7 (women)
Proximal LAD (mm) 3.6 ± 0.5 (men)
3.2 ± 0.5 (women)
3.5 ± 0.5 (men)
2.9 ± 0.4 (women)
3.3 ± 0.5 (Kimball et
al)
Mid-LAD (mm) 2.3 ± 0.4 (men)
2.2 ± 0.5 (women)
2.0 ± 0.4 (men)
1.8 ± 0.2 (women)
Distal LAD (mm) 1.1 ± 0.4 (men)
0.9 ± 0.3 (women)
Proximal LCx (mm) ∗ 3.4 ± 0.5 (men)
2.9 ± 0.6 (women)
3.1 ± 0.7 (men)
2.6 ± 0.6 (women)
Proximal RCA (mm) † 3.9 ± 0.6 (men)
3.3 ± 0.6 (women)
3.4 ± 0.7 (men)
3.0 ± 0.5 (women)

43. References
Grossman’s Textbook of Cardiac Catheterization
Kern’s Handbook of Interventional Catheterization
Hurst’s The Heart13th Edition
Braunwalds Heart Disease 9th edition
Grey’sAnatomy