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Anatomical basis of coronary intervention

  1. 1. ANATOMICAL BASIS OF CORONARY INTERVENTIONS (ARTERIES AND VEINS) Speaker Dr Avijit Bhaumik, 2nd year MD PGT, Department of Medicine, Medical College, Kolkata Chairperson Prof. S. Guha , Head,Department of Cardiology, Medical College,Kolkata
  2. 2. TODAY’S DISCUSSION • INTRODUCTION • CORONARY ARTERIAL ANATOMY • CORONARY ARTERIAL INTERVENTIONS WITH ANATOMICAL CORELATION • CORONARY VENOUS ANATOMY • CORONARY VENOUS INTERVENTIONS WITH ANATOMICAL CORELATION • TAKE HOME MESSAGES
  3. 3. INTRODUCTION • Coronary arterial interventions play a vital role in treatment of Coronary artery diseases(CAD) • Stable angina ; Unstable angina/NSTEMI ; STEMI • Coronary Interventions – PCI, CABG • Indications for coronary revascularisation • Syntax score
  4. 4. RIGHT CORONARY ARTERY • Origin- anterior aortic sinus of aorta • Diameter - 2.5 mm – 5 mm • Course-passes forwards and to the right between pulmonary trunk and right auricle -passes downwards along right part of AV groove -winds round inferior border of heart -passes upwards and to the left along posterior part of AV groove -Reaches crux of heart - anastomoses with LCX artery to the left of crux
  5. 5. RIGHT CORONARY ARTERY Branches of Right Coronary Artery • Right conus artery • Atrial branches • Anterior ventricular branches( largest one is the acute marginal artery) • Posterior ventricular branches • Posterior interventricular(descending) artery
  6. 6. RIGHT CORONARY ARTERY Right coronary artery supplies  Whole of right atrium  A portion of left atrium(posterior aspect)  Most of right ventricle except a strip along anterior interventricular groove  Postero inferior one third of ventricular septum, adjoining part of left ventricle  SA node (65% cases), AV node (80-90% cases)
  7. 7. Left anterior oblique view showing normal RCA
  8. 8. Partial occlusion of RCA
  9. 9. LEFT CORONARY ARTERY • Origin - left posterior aortic sinus • Diameter- 3 mm – 6 mm • Course - passes behind pulmonary trunk appears forwards and to the left between the pulmonary trunk and left auricle it divides into two branches, anterior interventricular and circumflex no significant branches arises from the trunk
  10. 10. • Left coronary artery supplies  Most of the left atrium  Left ventricle except a strip along posterior and inferior surface of heart  Antero superior 2/3 rd of ventricular septum  SA node (35 % cases)  AV node (10-20% cases)
  11. 11. ANTERIOR INTRAVENTRICULAR ARTERY • Continuation of left coronary artery • Course-Descends along anterior intraventricular groove Winds round the incisura apicis cordis Anastomoses with posterior interventricular artery in posterior interventricular groove • Branches- ventricular branches ( diagonal artery, left conus artery) septal branches
  12. 12. CIRCUMFLEX ARTERY • Arises from left coronary artery • Course- passes along left part of atrio ventricular groove winds round left border of heart occupies posterior part of AV groove anastomoses with RCA • Branches-atrial branches, anterior and posterior ventricular branches, left marginal artery, posterior intraventricular artery(10-20% cases), S.A. nodal aretry(35% cases)
  13. 13. Right anterior oblique coronary angiographic view showing LMCA, LAD and LCX
  14. 14. Occlusion of LAD
  15. 15. Narrowing of LMCA
  16. 16. INCIDENCE OF STENOSIS IN DIFFERENT CORONARY ARTERIES • Average frequency of narrowing of 3 major arterial trunks are as follows- LAD -40-50% LCX – 15-20% RCA-30-40% • Other infrequent locations of coronary occlusion are- LMCA Diagonal branch of LAD Left marginal of LCX
  17. 17. ANATOMICAL VARIATIONS OF CLINICAL SIGNIFICANCE • Ostial position, number • Absent LMCA, LAD and LCX having ostial origin • RCA- origin from opposite sinus, split RCA, Shephard’s crook RCA • Dual LAD • Dominance, super dominance • Myocardial bridging
  18. 18. MYOCARDIAL BRIDGING
  19. 19. SHEPHARD’S CROOK CORONARY ARTERY
  20. 20. SYNTAX SCORE (Synergy between PCI with Taxus and cardiac surgery trial.) • Angiographic grading tool to determine complexity of coronary artery disease • Syntax score is used to choose between PCI and CABG for revascularisation • Includes only anatomical charecteristics of CAD
  21. 21. SYNTAX SCORE • Points to individual lesion in coronary tree that has >50% diameter narrowingin vessels>1.5mm • Coronary tree is divided into 16 segments according to AHA classification
  22. 22. SYNTAX SCORE • Coronary arterial segments discussed • Clinical relevance of this segments • Dominance- left/right • Other anatomic features that determine whether PCI is feasible or not includes
  23. 23. • Aorto ostial lesion • Tortuisity of vessel
  24. 24. • Lesion length • Presence of side branch • Total occlusion blunt stump bridging collateral • Trifurcation • Bifurcation • Side branch angulation
  25. 25. Bifurcation Trifurcation
  26. 26. Lesion length > 20mm
  27. 27. Diffuse disease Thrombus
  28. 28. SYNTAX SCORE • SYNTAX SCORE is calculated with the help of calculator • If syntax score< 21 - PCI • If Syntax score >34 - CABG • If Syntax score 21-34- PCI/ CABG • Drawbacks
  29. 29. PERCUTANEOUS CORONARY INTERVENTION • Andreas gruentzig first performed PTCA in 1977 • Since then various modifications and developments have occurred • Vascular access- femoral artery radial artery brachial artery • procedure
  30. 30. ENTERING THE OSTIUM
  31. 31. PERCUTANEOUS CORONARY INTERVENTION
  32. 32. PERCUTANEOUS CORONARY INTERVENTION • ADVANTAGES Less invasive Shorter hospital stay Lower initial cost Easily repeated Effective in relieving symptoms • DISADVANTAGES Restenosis Incomplete revascularisation Relative inefficacy with low LVEF Limited to specific anatomic subsets Less favourable outcome in diabetics
  33. 33. CABG • A graft is used to bypass the stenosed segment of coronary artery • Done by midline sternotomy • Graft is taken from the internal mammary artery or the saphenous vein • Uncommon graft sites- radial artery, ulnar artery, gastro epiploic artery, inferior epigastric artery
  34. 34. CABG
  35. 35. CABG • ADVANTAGES Wider applicability Ability to achieve complete revascularisation Favourable outcome in diabetics Effective in relieving symptoms • DISADVANTAGES Cost Morbidity Patient preference
  36. 36. CORONARY VENOUS ANATOMY
  37. 37. CORONARY VENOUS ANATOMY • CORONARY SINUS Situated in the posterior part of AV groove receives 60% of venous blood of heart begins in the left part of AV groove where it receives the great cardiac vein ends in sinus venarum of right atrium. the AV nodes lies just above the opening
  38. 38. • Branches- great cardiac vein middle cardiac vein small cardiac vein posterior vein of the left ventricle oblique vein of left atrium Veins not draining into coronary sinus- anterior cardiac veins venae cordis minimi right marginal vein( occasionally)
  39. 39. CORONARY VENOUS ANATOMY – CLINICAL IMPLICATIONS • Gateway for left ventricular epicardial lead placement in CRT • Placement of octapolar or decapolar catheter in coronary sinus during EP study for supraventricular tachycardia • Coronary sinus blood sampling • Stem cell transplantation
  40. 40. CORONARY VENOUS SEGMENTS
  41. 41. CRT
  42. 42. CRT
  43. 43. CORONARY SINUS CATHETER IN EP STUDY
  44. 44. STEM CELL TRANSPLANT
  45. 45. TAKE HOME MESSAGES • PCI AND CABG are the revascularisation procedures used. • ANATOMY of the coronary artery play vital role in choosing between PCI and CABG • Some anatomic variations causes difficulty in PCI • CRT, EP studies, stem cell transplantation make use of the coronary venous anatomy.
  46. 46. Thank you

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