Basics of Coronary Angiography for beginners, MD, DNB, DM students, Nurses, cathlab technicians, physicians and other healthcare members . hope you will learn something from this ppt. 😀

1. Coronary Angiography
Dr. Hewad Gulzai
Consultantan Interventional Cardiologist
MD, PGCC, FNIC, FIC

2. • Coronary angiography remains the gold standard for detecting
clinically significant atherosclerotic coronary artery disease
• The technique was first performed by Dr. Mason Sones at Cleveland
clininc in 1958

3. Goals
• To visualize coronary arteries, branches, collaterals and anomalies
• Precise localization relative to major and minor side branches,
thrombi and area of calcification
• To visualize vessel bifurcations, origin of side branches and specific
lesion characteristics (length, eccentricity, calcium etc)

4. History
• 1927- Egas Moniz: Cerebral angiography
• 1929- Werner Forssmann: Cardiac Catheterization
• 1940- Andre Cournand and Dickinson Richards: Catheterization and
hemodynamics

5. Coronary artery
• Coronary artery is a vasavasorum that supplies the heart.
• Coronary comes from the latin “Coronarius” meaning “Crown”.
The everage LAD is 14.7 cm long, RCA 9.8 cm and LCX 9.3 cm According
to Gibson and colleagues.

6. Coronary artery
• The coronary artery arises just superior to the aortic valve and supply
the heart
• The aortic valve has three cusps
# Left coronary (LC)
#Right coronary (RC)
# Posterior non-coronary (NC) cusps

7. Right coronary artery
• Originates from right coronary sinus of Valsalva
• Courses through the right AV groove between the right atrium and
right ventricle to the inferior part of the septum.

8. Branches of RCA

9. • Conus branch- 1st branch supplies the RVOT
• Sinus node artery-2nd branch –SA-node. (in 40% originate from LAD)
• Acute marginal arteries- arise at acute angle and runs along the
margin of the right ventricle above the diaphragm.
• Branch to AV node
• PDA-supply lower part of the ventricle septum & adjacent ventricle
walls arises from RCA in 85% of cases.

10. Area of distribution
Rt Coronary Artery
1) Right atrium
2) Ventricles
a) Greater part of rt. ventricle
b) Small part of left ventricle adjoining post IV groove.
c) Posterior part of IV septum
d) Whole of conducting system of the heart except part of the left
branch of AV bundle

11. Left main coronary artery (LMCA)
• LMCA originates from the left coronary cusp and bifurcates to give
rise to LAD & LCX
• Long LMCA when the length is > 15 mm
• Short LMCA when the length is < 5 mm
• Occasionally a third branch vessel, the Ramus Intermedius arise from
the LMCA

12. Left coronary artery
• Arises from left coronary cusp, travels between RVOT anteriorly and
left atriumposteriorly.

13. LAD distribution
1) Left atrium
2) Ventricles
i) Greater part of the left ventricle except the area adjoining the
posterior IV groove.
ii) A small part of the right ventricle adjoining the anterior IV groove.
iii) Anterior part of the IV septum
iv) A part of the left br. Of the AV bundle

14. Dominance
• Determined by the arrangement that which artery reaches crux and
supply PDA- AV node
• The right coronary artery is dominant in 80% cases
• 10% case branch of LCX
• 10% both rt and lt coronary artery supply posterior IV septum &
inferior surface of the left ventricle---co-dominant.

15. Dominance

18. Indication for cardiac catheterization
• Before a decision to perform an invasive procedure such as cardiac
catheterization, the operator should conduct a thorough review of
patient’s symptoms, traditional risk factors, physical examination
findings, laboratory test results, 12 lead ECG and additional cardiac
noninvasive test results, where applicable.
• A planned interventional procedure should include careful
consideration of the
1. Anticipated benefit of the procedure.
2. Potential treatment alternatives
3. Risk of proceeding versus the risk of alternative treatments

19. Common diagnostic catheterization
laboratory procedures
Procedure Goals of procedure
Left hear catheterization Evaluation of systemic and left ventricular pressure and assessment of transvalvular
aortic pressure gradient
Right heart
catheterization
Evaluation of right-side cardiac pressure, pulmonary artery pressure, PCWP and
cardiac output. Can also include vasodilator challenges to evaluate trasnspulmonic
gradient.
Coronary angiography Presence, location and severity of CAD, can include visualization of arterial and
venous bypass grafts.
Left ventriculography Evaluation LV function, MR and ventricular defects.
Endmyocardial biopsy Evaluation of transplant rejection and primary myocardial disease
Peripheral angiography Evaluation of presence, location and severity of PAD (including anomalous anatomy)

20. Indications
• Establish CAD
• To define coronary anatomy and formulate management plan
• Emergent revascularization in STEMI
• To confirm invasive diagnosis of CAD
• Left ventricular dysfunction, ventricular arrhythmias,ambiguous non
invasive test results, out hospital cardiac arrest survivors
• Pre Surgical evaluation

21. Indication
• Coronary Artery disease
• Stable angina
• Unstable angina
• Atypical angina
• Stress test positive for significant ischemia
• Acute myocardial infarction
• Before primary PCI
• Failed thrombolysis
• Cardiogenic shock
• Mechanical complications (Rupture of the ventricular septum, Acute MR)
• Status post resuscitation (survived sudden cardiac death)
• Acquired valvular disease

22. Indication
• Congenital heart disease
• Aortic dissection
• Pericardial disease
• Cardiomyopathies
• Status post cardiac transplant
• Before surgical treatment of cardiac tumors
• Before EPS & RFA for VT
• Before drug therapy with class I antiarrhythmic agents

23. Current Clinical Practice Guidelines on the Indications for Coronary
Angiography in Stable CAD, UA/NSTEMI, and STEMI

26. Contraindiaction
• No Absolute contraindication
• Anemia
• Renal dysfunction
• Active infection/Fever
• Coagulopathy, High bleeding risk
• Contrast allergy
• Untreated electrolyte disorder
• Decompensated congestive heart failure
• Uncontrolled hypertension
• CVA, GI hemorrhage, Pregnancy, inability for patient cooporation
• Drug overdose/ intoxication
• Lack of inform consent

27. Before the procedure
• After patient is properly identified, the procedure must be explained
before consent can be signed
• Baseline vital signs will be done and as long as these are within the
doctor’s interest, can proceed with the procedure
• Blood tests must be done including BUN, Creat, PTT,INR,Insulin/Sugar
level,CBC and viral markes

28. Patient prep
• After patient put on table, the area being be puncture must be free
from hair
• Hair removal done by disposable electronic razor
• Patient must be surgically cleaned with hospital approved sterile
surgical prep solution

29. Sterile Field and Patient
• The technologist working with cardiologist must be scrubbed in
following basic sterile surgical technique
• The patient is the draped from neck down with sterile drapes
• All equipment (Radiation shields, image intensifier, instrument used
to manipulate machine) must be prepped with sterile covers

30. Sterile Equipment Needed
• Procedure tray should be include:
-sterile gown and gloves for scrub tech and doctor
-sterile towels and drapes for procedure
-equipment covers, Gauze, scalpel, needle, scissors, hemostats
- Syringes for heparin/saline flush, lidocaine and bold draw
- labels with marking pen for any item filled with a solution
-basin for saline/heparin mixture

31. EQUIPMENTS
• Cardiac catheterization laboratory

32. Coronary Angiography Catheters

33. Contrast material
• High osmolality ionic contrast media:
• Not used nowadays
• High incidence of adverse events
• Low osmolar non ionic contrast agents:
• Most commonly used agent
• Well tollersted
• Iso osmolar non ionic contrast agents

35. Contrast injection
• LAD: 6-8 ml over 2-3 seconds
• RCA: 4-6 ml over 2-3 seconds
• Should be adequate to fill the coronary artery completely without
streaming
• Excessive contrast injection should be avoided
• Cine acquisition (@ 10 fps) should continue till contrast clear from
system

36. Access sites
• Femoral
• Most frequently used access site
• Ease of access, lesser contrast and radiation exposure, freedom to upgrade to
bigger size sheaths
• Need for immobilization, local site complication: main drawbacks

37. Femoral

38. Radial
• No need for immobilization
• Lower rate of local vascular complication
• Increasingly being used as primary access site
• Slightly higher contrast and radiation exposure for biginners
• Spasm, loops, failure to get access may require switch to femoral
route
• Other- Brachial, Ulnar, Axillary

39. Radial access tools

40. Radial Art puncture

41. Angiographic projection

42. Angiographic projection

43. Angiographic projection

44. Angiographic view

45. RCA view

48. Standard Angiographic Projections

49. Angiogram-interpretation
• Evaluation of the extent and severity of coronary calcification just
prior to or soon after contrast opcification
• Lesion quantification in at least 3 orthogonal view:
Severity
Calcification
Presence of ulceration/thrombus
Degree of tortuosity
Lesion calcification
Reference vessel size

50. Analysis of the coronary angiogram
Degree of stenosis Diameter of stenosis (%)
Normal <25
Low grade 25-49
Intermediate grade 50-74
High grade 75-90
Subtotal 91-99
Total 100

52. AHA/ACC Lesion Classification

54. Collateral circulation

63. Severe calcifications in the proximal and middle left anterior
descending artery (LAD).

64. Severe calcifications in the right coronary artery (RCA). Left,
Calcification can be seen before contrast injection

65. Grade 3 intracoronary thrombus in the proximal segment of
the right coronary artery

67. Type B coronary dissection

68. RCA Spasm

69. Myocardial Bridge in mid LAD

70. coronary perforations

71. Complication
• Life threatening complication are rare 1/1000 but more common in
patients with serious disease eg. LM disease, aortic or peripheral
vascular disease.

72. Major Complication
• MI
• Stroke
• Renal failure
• Aortic or coronary rupture
• Cardiac rupture
• Air embolism
• Arrhythmias
• Peripheral vascular damage
• Pericardial tamponade
• Catheter fragmentation and embolism

73. Minor complication
• Hematoma
• Bleeding
• infection
• Angina
• Vaso vegal reaction
• Allergies to contrast and drugs