First step of coronary angiography

Copyright © 2011 American Heart Association.
First Step of Coronary
Angiography
Dr. Naresh Sen
Consultant Cardiologist

Overview
Coronary Angiography
 Indications
 Contraindications / Caution
 Equipment
 Equipment & Technique
 Precautions
 Pressure monitoring
 Zeroing and Referencing
 Guide catheter selection
 Flow rate and volume
 Standard angiographic views
 Angiogram- interpretation
 ACC/AHA lesion classification
 Other definitions
 TIMI flow and perfusion grades
 Congenital coronary anomalies

Indications
Known or suspected CAD (Class I and III only)
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
 CCS class III and IV angina on medical treatment
 High-risk criteria on noninvasive testing regardless of anginal severity
 Patients who have been successfully resuscitated from sudden cardiac
death or have sustained (>30 seconds) monomorphic ventricular
tachycardia or non-sustained (<30 seconds) polymorphic ventricular
tachycardia
 Angina in patients who are not candidates for coronary
revascularization or in whom revascularization is not likely to
improve quality or duration of life
 As a screening test for CAD in asymptomatic patients
 After CABG or angioplasty when there is no evidence of ischemia on
noninvasive testing
 Coronary calcification on fluoroscopy, electron beam computed
tomography, or other screening tests without criteria listed above
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

Indications
Patients With Nonspecific Chest Pain
 High-risk findings on noninvasive testing
 Patients with recurrent hospitalizations for chest pain who have
abnormal (but not high-risk) or equivocal findings on noninvasive
testing
 All other patients with nonspecific chest pain

Indications
Patients With Unstable Acute Coronary Syndromes (Class I and III only)
 An early invasive strategy (i.e., diagnostic angiography with intent to
perform revascularization) is indicated in UA/NSTEMI patients who have
refractory angina or hemodynamic or electrical instability (without
serious comorbidities or contraindications to such procedures)
 An early invasive strategy is indicated in initially stabilized UA/NSTEMI
patients (without serious comorbidities or contraindications to such
procedures) who have an elevated risk for clinical events
 An early invasive strategy is not recommended in patients with extensive
comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks
of revascularization and comorbid conditions are likely to outweigh the
benefits of revascularization
 An early invasive strategy is not recommended in patients with acute
chest pain and a low likelihood of ACS
 An early invasive strategy should not be performed in patients who will
not consent to revascularization regardless of the findings
Source: Anderson JL et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1–157

Indications
Patients With STEMI (Class I and III only)
 Diagnostic coronary angiography should be performed:
a. In candidates for primary or rescue PCI
b. In patients with cardiogenic shock who are candidates for
revascularization
c. In candidates for surgical repair of ventricular septal
rupture (VSR) or severe MR
d. In patients with persistent hemodynamic and/or electrical
instability
 Coronary angiography should not be performed in patients with
extensive comorbidities in whom the risks of revascularization
are likely to outweigh the benefits
Source: Antman EM et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. 2004. Available at www.acc.org/clinical/guidelines/stemi/index.pdf.

Indications
Patients With Post-revascularization Ischemia (Class I and III only)
 Suspected abrupt closure or subacute stent thrombosis after percutaneous
revascularization.
 Recurrent angina or high-risk criteria on noninvasive evaluation within 9
months of percutaneous revascularization
 Symptoms in a post bypass patient who is not a candidate for repeat
revascularization
 Routine angiography in asymptomatic patients after percutaneous
transluminal coronary angioplasty (PTCA) or other surgery, unless as
part of an approved research protocol
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

Indications
Perioperative Evaluation Before (or After) Noncardiac Surgery (Class I and III only)
 Evidence for high risk of adverse outcome based on noninvasive test results
 Angina unresponsive to adequate medical therapy
 Unstable angina, particularly when facing intermediate or high-risk
noncardiac surgery
 Equivocal noninvasive test result in a high-clinical- risk in patients
 Low-risk noncardiac surgery, with known CAD and no high-risk results on
noninvasive testing
 Asymptomatic after coronary revascularization with excellent exercise capacity
(>7 METs)
 Mild stable angina with good left ventricular function and no high-risk
noninvasive test results
 Noncandidate for coronary revascularization owing to concomitant medical
illness, severe left ventricular dysfunction (eg, LVEF <0.20), or refusal to
consider revascularization.
 Candidate for liver, lung, or renal transplant >40 years old as part of
evaluation for transplantation, unless noninvasive testing reveals high risk for
adverse outcome

Indications
Patients With Valvular Heart Disease (Class I and III only)
 Before valve surgery or balloon valvotomy in an adult with chest
discomfort, ischemia by noninvasive imaging, or both
 Before valve surgery in an adult free of chest pain but of substantial
age and/or with multiple risk factors for coronary disease
 Infective endocarditis with evidence of coronary embolization
 Before cardiac surgery for infective endocarditis when there are no
risk factors for coronary disease and no evidence of coronary
embolization
 In asymptomatic patients when cardiac surgery is not being
considered
 Before cardiac surgery when preoperative hemodynamic assessment
by catheterization is unnecessary, and there is neither preexisting
evidence of coronary disease nor risk factors for CAD

Indications
Patients With Congenital Heart Disease (Class I and III only)
II IIa IIb IIIII IIa IIb IIIII IIa IIb IIIIIa IIb III
 Before surgical correction of congenital heart disease when chest
discomfort or noninvasive evidence is suggestive of associated CAD
 Before surgical correction of suspected congenital coronary anomalies
such as congenital coronary artery stenosis, coronary arteriovenous
fistula, and anomalous origin of left coronary artery
 Forms of congenital heart disease frequently associated with coronary
artery anomalies that may complicate surgical management
 Unexplained cardiac arrest in a young patient
 In the routine evaluation of congenital heart disease in asymptomatic
patients for whom heart surgery is not planned

Indications
Patients With CHF (Class I and III only)
II IIa IIb IIIII IIa IIb IIIII IIa IIb IIIIIa IIb III
 CHF due to systolic dysfunction with angina or with regional wall
motion abnormalities and/or scintigraphic evidence of reversible
myocardial ischemia when revascularization is being considered
 Before cardiac transplantation
 CHF secondary to postinfarction ventricular aneurysm or other
mechanical complications of MI.
 CHF with previous coronary angiograms showing normal coronary
arteries, with no new evidence to suggest ischemic heart disease

 There are no absolute contraindications to cardiac catheterization
 Relative contraindications include:
 Coagulopathy (Radial approach can be attempted based on
urgency)
 Decompensated congestive heart failure
 Uncontrolled hypertension
 Pregnancy
 Inability for patient cooperation
 Active infection
 Renal failure
 Contrast medium allergy
Contraindications

 Conscious sedation using a narcotic and a benzodiazepine
 Vascular access: Either femoral (described in the section on vascular
access and closure devices), radial, or brachial
 Flush the selected diagnostic catheter with saline to ensure an air-free
system
 Once arterial access is obtained (as described in the section on vascular
access and closure devices) a catheter of appropriate size and
configuration is advanced over a 0.035 or 0.038 inch guidewire
 Once in the ascending aorta, the guidewire is removed, the catheter
allowed to bleed back to remove any thrombus or atherosclerotic debris
 The catheter is then connected to a manifold assembly connected to a
pressure transducer for continuous central pressure monitoring
 The catheter is flushed to ensure an air-free system
Equipment & Technique

 Zeroing and referencing: The transducer should be opened to air to
zero the system. Care must be taken to ensure that the pressure
transducer is at the level of phlebostatic axis, which is roughly the
midportion between the anterior and posterior chest wall along the
left 4th
intercostal space
 The central aortic pressure should be recorded and compared with
the cuff measured brachial pressure. If there is considerable
difference between the two, subclavian artery stenosis should be in the
differential
 The catheter should then be filled with 3-4 cc of contrast and
advanced to engage the coronary ostium, in the LAO projection
 After ensuring that there is no ventricularization or damping of the
pressure, a 2 to 3 cc of contrast should be injected to confirm the
position of the catheter in the coronary ostium
Technique

 Coronary angiography should be performed in standard views in
orthogonal planes to visualize the lesion and serve as a roadmap
for PCI
 Non-standard views should be considered based on the lesion
location, orientation of the heart, and patient body habitus
 Before injecting contrast, with every view care should be taken to
ensure no ventricularization or damping of the pressure wave
forms
Technique

 The overall risk of major complications with coronary angiography is 1-
2%. This includes death, myocardial infarction, stroke, bleeding,
vascular complications and contrast reaction.
Complications

 Selecting the right catheter is important and is dependent upon the following:
 Access site: Choice of catheters depends to certain degree on the access site -
femoral vs. radial vs. brachial
 Aortic width: Normal aortic width - 3.5 to 4.0 mm; Narrow- <3.5 mm, Dilated
>4.0 mm
 Coronary ostial location: high vs. low; anterior vs. posterior
 Coronary ostial orientation: Superior, inferior, horizontal or shepherd’s
crook (for RCA only)
 Standard workhorse catheters for routine coronary angiography are Judkins right
size 4 (JR4) and Judkins left size 4(JL4) and the ostia are engaged in the LAO
projection
 Always ensure co-axial alignment of the catheter
 Catheters generally have two curves: Primary (distal) curve and a secondary
(proximal) curve. The distance between the two curves is the length of the catheter
 Shorter curve more ideal for superior take-offs
 Longer curve more ideal for inferior take-offs
Catheter Selection

 If using a power injector for contrast opacification, the following settings
may be considered:
 RCA- 2 to 3ml/sec for 2 to 3 seconds, i.e., 3 for 6 represents a flow rate
of 3ml/sec for a total volume of 6ml
 LCA- 3 to 4ml/sec for 2 to 3 seconds, i.e., 4 for 8 which represents a
flow rate of 4ml/sec for a total of 8ml
 Ventriculography - 10 to 16ml/sec for 30 to 55ml, i.e., 13 for 39 which
represents a flow rate of 13ml/sec for a total of 39ml
 Common carotid artery - 8ml/sec for 10 cc
 Internal carotid artery - 8ml/sec for 8cc
 Vertebral artery - 7ml/sec for 7cc
 Renal artery - 5ml/sec for 5 to 10cc
 Iliofemoral - 7 to 9ml/sec for 70 to 120 cc
Flow Rate and Volume
Source: Baim, DS et al. Grossman’s Cardiac catheterization, angiography and intervention. Lippincott Williams & Wilkins, Philadephia

Standard Angiographic Views
 LAO-Caudal view: 400
to 600
LAO and 100
to 300
caudal
 Best for visualizing left main, proximal LAD and proximal LCx
 RAO-Caudal view: 100
to 200
RAO and 150
to 200
caudal
 Best for visualizing left main bifurcation, proximal LAD and the
proximal to mid LCx
 Shallow RAO-Cranial view: 00
to 100
RAO and 250
to 400
cranial
 Best for visualizing mid and distal LAD and the distal LCx (LPDA
and LPL)
 Separates out the septals from the diagonals
 LAO-Cranial view: 300
to 600
LAO and 150
to 300
cranial
 Best for visualizing mid and distal LAD, and the distal LCx in a left
dominant system
 Separates out the septals from the diagonals
Left Coronary Artery

 PA projection: 00
lateral and 00
cranio-caudal
 Best for visualizing ostium of the left main
 PA-Caudal view: 00
lateral and 200
to 300
caudal
 Best for visualizing distal left main bifurcation as well as the
proximal LAD and the proximal to mid LCx
 PA-Cranial view: 00
lateral and 300
cranial
 Best for visualizing proximal and mid LAD
 Left lateral view:
 Best for visualizing proximal LCx, proximal and distal LAD
 Also good for visualizing LIMA to LAD anastomotic site
Left Coronary Artery (other views)

 LAO 30: 300
LAO
 Best for visualizing ostial and proximal RCA
 RAO 30: 300
RAO
 Best for visualizing mid RCA and PDA
 PA Cranial: PA and 300
cranial
 Best for visualizing distal RCA bifurcation and the PDA
Right Coronary Artery

 An easy way to identify the tomographic views 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
CENTER
PA view
No diaphragm
shadow
Caudal
view
Spine to
the
RIGHTLAO view
Diaphragm
shadow
Cranial view

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

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

PA0 Caudal 30
LM
LAD
Diagonal
Septals
Distal
LAD
LCx
LAO 50 Caudal 30
OM
LM
LAD
Diagonal
Distal
LAD
LCx
OM
‘Spider’ view
bifurcation and proximal
LAD and LCx
bifurcation, proximal LAD and LCx
and OM

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

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

ACC/AHA Lesion Classification
 Type A Lesion: Minimally complex, discrete (length <10 mm),
concentric, readily accessible, non-angulated segment (<45°), smooth
contour, little or no calcification, less than totally occlusive, not ostial in
location, no major side branch involvement, and absence of thrombus
 Type B Lesion: Moderately complex, tubular (length 10 to 20 mm),
eccentric, moderate tortuosity of proximal segment, moderately
angulated segment (>45°, <90°), irregular contour, moderate or heavy
calcification, total occlusions <3 months old, ostial in location,
bifurcation lesions requiring double guidewires, and some thrombus
present
 Type C Lesion: Severely complex, diffuse (length >2 cm), excessive
tortuosity of proximal segment, extremely angulated segments >90°, total
occlusions >3 months old and/or bridging collaterals, inability to protect
major side branches, and degenerated vein grafts with friable lesions.
Source: Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and
Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiology. 1988;12:528-45

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

TIMI Flow Grades
 TIMI 0 flow: absence of any antegrade flow beyond a coronary
occlusion
 TIMI 1 flow: (penetration without perfusion) faint antegrade
coronary flow beyond the occlusion, with incomplete filling of the distal
coronary bed
 TIMI 2 flow: (partial reperfusion) delayed or sluggish antegrade flow
with complete filling of the distal territory
 TIMI 3 flow: (complete perfusion) is normal flow which fills the distal
coronary bed completely
Gibson CM, et al. Am Heart J. 1999;137:1179–1184

TIMI Myocardial Perfusion Grades
 Grade 0: Either minimal or no ground glass appearance (“blush”) of the
myocardium in the distribution of the culprit artery
 Grade 1: Dye slowly enters but fails to exit the microvasculature. Ground glass
appearance (“blush”) of the myocardium in the distribution of the culprit lesion that
fails to clear from the microvasculature, and dye staining is present on the next
injection (approximately 30 seconds between injections)
 Grade 2: Delayed entry and exit of dye from the microvasculature. There is the
ground glass appearance (“blush”) of the myocardium that is strongly persistent at
the end of the washout phase (i.e. dye is strongly persistent after 3 cardiac cycles of
the washout phase and either does not or only minimally diminishes in intensity
during washout).
 Grade 3: Normal entry and exit of dye from the microvasculature. There is the
ground glass appearance (“blush”) of the myocardium that clears normally, and is
either gone or only mildly/moderately persistent at the end of the washout phase (i.e.
dye is gone or is mildly/moderately persistent after 3 cardiac cycles of the washout
phase and noticeably diminishes in intensity during the washout phase), similar to
that in an uninvolved artery.
Gibson CM, et al. Circulation. 2000;101:125-130

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
 Treatments: include observation,
surgery, occlusive coiling, covered stents,
therapeutic coiling
Image courtesy Dr. Frederick Feit

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

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

First step of coronary angiography

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