coronary anatomy, interventional cardilogists, right coronary artery, left main coronary, left circumflex artery, left anterior descending artery

1. Coronary Anatomy for
Interventional Cardiologists
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com
CRT 2014
Washington
DC, USA

5. Right Coronary Artery
• Origin
Right aortic sinus (lower origin than LCA)
• Course
Down right AV groove toward crux of the heart,
gives off PDA (85%) from which septals arise,
continues in LAV groove giving off posterior LV
branches (posterolaterals). PDA may originate
more proximally, bifurcate early or be small with
part of “its territory” supplied by an acute marginal
branch.
• Supplies
25% to 35% of Left Ventricle
Basic Anatomy

6. Right Coronary Artery
• Conus Artery
usually very proximal; (~50% have a separate origin)-
courses anteriorly and upward over the RV outflow tract
toward the LAD. May be an important source of collaterals.
• SA Nodal Artery
(~60%) usually 2nd branch of RCA-courses obliquely
backward through upper portion of atrial septum and
anteromedial wall of the RA-supplies SA node, usually RA
and sometimes LA.
Other Branches

7. Right Coronary Artery
• 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.
• PDA
Supplies inferior wall, ventricular septum,
posteromedial papillary muscle.
Other Branches

8. Right Coronary Artery
• LAO (30) Cranial(30)
particularly for distal bifurcation (AP Cranial
may be better).
• RAO
main shaft; cranial enhances distal vessels and
very proximal; caudal may help with
Shepherd’s crook.
• Lateral
bifurcations with RV branches-distal
bifurcation, particularly with cranial.
Optimal View(s)

9. RAO Angiogram of RCA

10. Left Coronary Artery
• Origin
upper portion of left aortic sinus just below the sinotubular
ridge. Typically 0-10 mm in length. Rarely no LM (separate
origins).
• Catheterization Technique
“The Judkins’ 4-Left coronary catheter will find the LCA
orifice unless thwarted by the operator”. Just in case-other
Judkins sizes for smaller or larger aortas; Amplatz, XB type
curves. Watch for “damping”; For separate ostia-separate
catheters, larger for Cx, or counterclockwise rotation for
LAD.
• Optimal Views
LAO caudal and cranial; AP-caudal, cranial or flat. Limit
views. May need IVUS
Left Main Coronary Artery

13. Left Anterior Descending Artery
• Course
down the anterior interventricular groove-usually
reaches apex. In 22% of cases does not reach apex.
• Branches
septals and diagonals-supply lateral wall of LV,
anterolateral papillary muscle; 37% have median ramus
(courses like 1st diagonal).
• LAD
Supplies anterolateral, apex and septum; ~45%-55% of
left ventricle.

14. Left Circumflex Artery
• Origin
from distal LMCA.
• Course
down distal left AV groove.
• Branches
obtuse marginal, posterolaterals-supply posterolateral
LV, anterolateral papillary muscle. SA node artery-38%.
• Supplies
15%-25% of LV, unless dominant (supplies 40-50% of LV).

15. Left Coronary Artery
• AP (30)Caudal
LMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO
may be useful.
• AP (40)Cranial
LMCA, LAD, diagonals, septals, distal Cx-may need RAO to
separate LAD and Cx.
• (45)LAO (35) Cranial
LMCA, LAD, diagonals, septals, and distal Cx.
• (45)LAO (30) Caudal
LMCA, Cx,and prox LAD.
• Laterals (cranial, caudal)
may be helpful.
Optimal Views

16. Septal
LAD
Cx
Diagonal
AP Cranial View of LCA

17. Dominance:
• Definition 1:
the coronary artery which reaches the
crux of the heart and then gives off the
PDA
• Definition 2: (Allows for codominance)
the artery which gives off the PDA as well
as a large posterolateral branch

18. Left
Dominant
Circulation

19. LCA Angiogram
Distal LAD
Prox LAD
LM
OM
Distal Cx
Occluded Median Ramus
Dominant Cx AP Caudal

20. LCA Angiogram-Dominant Cx LAO-Caudal
Distal LAD
LM
Prox Cx
LPDA
Occluded
Median
Ramus
Prox LAD

21. The Coronary Arteries Are Complementary
• Large PDA Small LAD
• Huge Cx (posterolaterals)
 Small RCA continuation in AV
Groove
• Etc, etc, etc…..

22. Wrap Around LAD

23. Short LAD/Large RCA with Apical Extension

24. BYPASS GRAFTS
• SVG
Left coronary grafts generally arise from left
side of the aorta. Best cannulated with
Judkins’ Right, IMA, LCB or MP.
– Right sided grafts-arise from right side of the
aorta-MP usually best.
• IMA
don’t forget to check subclavians.
All distal vessels must be accounted for; op notes and old films are extremely helpful.

25. SVG-OM-LAO Caudal
Demonstrating Graft Ostium
Ostium

26. SVG-OM 1 AP Caudal
Demonstrating Anastomosis
SVG

27. LIMA to LAD
Origin from left subclavian (AP Cranial)

28. LIMA to LAD
Distal Anastomosis-AP Cranial
LIMA
LAD

29. RIMA to RCA

30. RIMA to RCA

31. Ulcerated Plaque

32. NORMMAL CORONARY ARTERY ANATOMY
BRAUNWALD, 2nd Ed; 1984
LAO
RAO

33. Branch of
RCA
Percentage Area perfused Best view
RCA RA & part of LA, RV, Posterosupirior
IVS,SA node AV node
60 LAO
Conus branch 60% (40%
separate)
RVOT RAO 30
SA nodal 59%,c39% Sinus node, RA,LA RAO 30
RV Branch 100% RV RAO 30
AM
AV node
100%
87.9%
Inferior& diaphramatic surface of RV
AV node
RAO,LAO
LAO CR
PD
PL/PLV
86%,c14%
20%
Post. & diaph. Area of septum
Post. & diaph LV wall
LAO, CR
LAO CR
RIGHT CORONARY ARTERY-ANATOMICAL CONSEDERATIONS
LVB 80%,c20% Diaphramatic surface of LV LAO CR
Braunwald;2nd ed,1984

34. Br. of LCA Percentage Area perfused Best view
LM Entire LV, LA except post.portion of
IVS when PD is br. of RCA
AP,RAO CR,
LAO CA,
LAD 98% Ant.2/3rd of IVS,ant. Portion of LV RAO,LAO, LAO
CR, RAO CA,
Ist diagonal
(1)
100% High lateral wall of LV LAO CR
Ist Septal (1) 99.8% Superior & ant. Portionof IVS RAO , RAO CR
Septals
(minor)
several
100% Inferior & ant. 1/3rd of IVS RAO CR
Second
Diogonal
(1or 3)
100% Lower lateral aspect of lv free wall LAO, LAO CR
LEFT CORONARY ARTERY-ANATOMICAL CONSEDERATIONS

35. Br. of
LCA
Percentag
e
Area perfused Best view
LCX 97% Obtuse margin of heart & its entire post. wall,
post.IVS when PD is br. of LCX
RAO,LAO, RAO
CA
OM (1 or
2)
97% Obtuse margin of heart and adjacent post. LV RAO,RAO CA
SA node 39%, 59 rca SA node RA, LA RAO, LAO
PL(1or 2) 80%,
rca 20%
Posterior & diaphramatic LV wall RAO
PD 18%,
(rca78%,2%
c)
Posterior IVS & Diaphramatic LV RAO
AV node 11.9% AV node, lower port of IAS LAO
LEFT CORONARY ARTERY-ANATOMICAL CONSEDERATIONS
Braunwald;2nd ed,1984

36. Right & left dominant depending on which PD artery cross the crux. When both
arteries reach the crux without crossing it ,the circulation is considered as
balance circulation
Braunwald 2nd ed; 1984
RIGHT DOMINANT(85%)
When PD arise from RCA & cross the crax
LEFT DOMINANT( 15%):
When PD arise from LCX & cross the crax
CODOMINANT ( BALANCE) 7.5%:
When RCA give rise to PDA & LCX gives rise to all posterolateral branches
Braunwald 6th ed;2001
RIGHT DOMINANT, LEFT DOMINANT & CODOMINANT

41. SEGMENTS OF RCA
RV
Acute marginal
BRAUNWALD, 2nd Ed; 1984

42. SEGMENTS OF LAD
BRAUNWALD, 2nd Ed; 1984
Distal

43. BRAUNWALD, 2nd Ed; 1984
PRINCIPAL SEGMENTS OF LCX

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