Coronary Angiography - Views - Dr Hafeesh Fazulu - PIMS

1. PUSHPAGIRI CARDIOLOGY 01-12-2021
Coronary Angiography Views
Dr Hafeesh Fazulu
DM Cardiology Resident
Pushpagiri Cardiology
Pushpagiri Medical College, Thiruvalla.
+91 999 570 6688
www.youtube.com/c/CardiologyLecturesDMDNB
Angiographic Projections

2. DEMO with 3D Anatomy ATLAS

3. • Coronary Views
• Chamber Views

4. 10 possible views
1) LAO Caudal - Spider view
2) RAO Caudal - to view LCx
3) LAO Cranial - LAD long and downwards, to view LAD and diagonal OSTIUMS
4) RAO Cranial -
5) Straight PA Cranial - mix view of both cranials (straight means - no cranial / caudal tilt)
6) Straight PA Caudal - mix view of both caudals
7) Straight PA – “center”
8) Straight LAO - to engage coronaries
9) Straight RAO - to make coronary ostium antero posterior
10) Lateral – “Left”.
• Right ??

5. X-ray cone standard positions
1, Posteroanterior (PA) cranial;
2, left anterior oblique (LAO) cranial;
3, LAO;
4, LAO caudal (spider);
5, PA caudal;
6, right anterior oblique (RAO) caudal;
7, RAO;
8, RAO cranial.
These views are taken at an angle to the horizontal (*)
with the exception of PA
(9) taken vertically and lateral
(10) taken from the side.

6. LEARNING TIPS
• Learn with wires.
• Learn with three fingers.
• Learn by drawing coronaries on an empty bottle.

7. Learn with wires

8. Learn with Fingers

11. Learn with bottle

12. Minimum Views
• LEFT
• LAO Caudal – LMCA and bifurcation
• LAO Cranial - LAD
• RAO Caudal – LCx
• RIGHT
• LAO – Prox & mid RCA
• LAO Cranial – crux and RPDA/RPLB

13. Terminologies
• Straight – no cranial or caudal angulation
• Shallow – <60 degrees [shallow angle]
• Steep - >60 degrees [steep angle]
“as the angle increases – more steep”

14. Image Intensifier
X-Ray Generator

15. “near the shoulder”

16. RAO vs LAO
• Spine
• Catheter Tip
• Direction of ribs

17. Spine position
• Spine on your left – RAO
• Spine on your right – LAO
• Spine is to the left of heart – LAO
• Spine is to the right of heart - RAO
RAO LAO

19. “tip looks towards you”

20. RAO LAO
1, Basal
2, lateral
3, apical
4, septal
1, Anterior basal
2, anterior
3, apical
4, inferior
5, inferior basal

21. Deep inspiration during Cranial views
• Will push the diaphragm down and out of the field.

22. Direction of Rib
• Ribs going down to your right hand – RAO
• Ribs going down to your left hand - LAO

23. Catheter tip
With open arms, place one arm over the spine or central catheter and other arm holds the tip of catheter.
RAO - RIGHT ARM holds catheter tip
LAO – LEFT ARM holds catheter tip
RAO 30 LAO 40

25. • RAO – looks at AV groove
• LAO – looks at Ventr. Septum (tangentially)

26. • RAO – divides heart into RA and RV
• LAO - divides heart into LV and RV

27. Cranial vs Caudal

28. AP VIEW

29. AP

32. General Rules
• Cranials – for LAD
• Caudals – for LCx
• Cranials – for distal segments
• Caudals – for proximal segments

33. LAO VIEW

34. • Left shoulder is Fordward
• LV is foreshortened
• Apex points towards the
viewer
• Rounded heart

35. LAO

36. Best for engaging coronaries.

37. Apex points towards the viewer
Rounded heart

38. LAO - Straight

39. LAO CAUDAL

42. LAO - Caudal

43. LAO 50
RAO 35

44. LAD is
foreshortened
after the
bifurcation

46. LAO - Caudal
Not good for
LAD ostium

47. LAO CRANIAL
“Mid and distal LAD view”
“Diagonals View”

48. “hold breath in
INSPIRATION”
“not a good working view”

50. Prox LAD maybe
foreshortened
Good for distal
LCX also
Good for mid
and distal LAD

51. Example of foreshortening !
LAO PA Cranial

53. Vs Lateral View

54. LAO - Cranial

55. LAO 45
Cranial 20
Optimal for visualization of the left anterior descending and the entire length of the diagonal branches

57. LAO - Cranial

58. • More LAO will bring the LAD away from the spine
• More Cranial will show the LM bifurcation well
• Tilts the LMCA down

60. RAO VIEW

61. • Right shoulder is Fordward
• LV is lengthened
• Apex points towards the left

62. RAO

64. RAO - Straight

67. RAO CAUDAL
“The Circ View”

69. Good OM brancing
Diagonals overlap
Degree of caudal
angulation – more
opening up of LAD - LCx

70. RAO - Caudal

71. RAO 30
Caudal 30

72. Not good for mid
LAD due to overlap
of diagnoals and
septals
4. OM Branchings

77. Cannot see ostium of LCx

78. Not LAD
Big diagonal mimicking LAD

80. Opening up of LAD & LCx – on being more CAUDAL
RAO Caudal - 0 RAO Caudal - 20 RAO Caudal - 30

81. Likewise, more cranial will congest
RAO Caudal - 0

82. RAO CRANIAL
“Prox LAD view”

83. BEHIND
FRONT
Not a good view for LCx
LCx is foreshortened

84. Good for very prox LAD
Good for Diagonal
bifurcations

90. LCx
LAD

91. PA CRANIAL
“RAO Cranial Alternative View”

96. PA CAUDAL
“Spider alternative”

101. RAO Cranial alternative
LAO Caudal alternative

102. LEFT/RIGHT LATERAL
“LIMA graft View”

103. “Ask to keep arms
above the head”
Rt hand Left hand
“widely separates
LAD and LCx”
Useful in occluded LAD

104. • Left Lateral – LAD is left
• Right Lateral – LCx is left

109. Lateral is for LIMA
Lateral view is best for LIMA insertion to mid LAD

110. Comparison of all 3 CRANIALS - LAD
LAD moves to opposite

111. Comparison of all 3 CAUDALS - LCx

112. RIGHT CORONARY

113. RIGHT CORONARY
LAO VIEW
The ‘C’ view of RCA

114. 1.LAO
2.LAO Cranial - RCA crux and bifurcations
3.RAO - mid RCA

115. LAO

116. C shape
Mid-RCA runs behind

120. RCA – after removing
the heart from the
view

122. RIGHT CORONARY
RAO VIEW
I named it – Pear Cut View

123. Mid RCA in RAO
RA – left
RV - right
“mid RCA cuts the RA RV into two”

124. RAO

131. RIGHT CORONARY
PA CRANIAL VIEW
“crux view”
“squatting RCA view”
or LAO Cranial View

132. Prox and mid
RCA folded on
itself -
squattting
RPDA
RPLV
RPDA
RPLV

133. RIGHT CORONARY
LAO CRANIAL VIEW
“another crux view”

135. Lesion specific approach

136. LMCA
• Ostium
• LAO Cranial / PA Cranial
• LAO Caudal – “higher xray dose”
• Bifurcation
• LAO Caudal

137. LAD
• Ostium
• RAO Caudal
• LAO Caudal
• Proximal
• RAO Caudal
• LAO Caudal
• Mid
• PA Cranial
• Distal
• RAO Cranial
• LAO Cranial
• Diagonal Ostiums
• LAO Cranial

138. LCx
• Ostium
• LAO Caudal
• Proximal
• RAO Caudal
• Mid
• RAO Caudal
• Distal
• RAO Cranial
• OM bifurcations
• PA Caudal
RAO Caudal is best view for LCx in general

139. RCA
• Ostium
• LAO
• LAO Cranial
• Proximal
• LAO
• LAO Cranial
• Mid
• RAO
• Lateral
• LAO
• Crux
• LAO Cranial
• Distal (PDA/PLV)
• AP Cranial

142. LAD
Optimal angiographic views
for specific segments of the
left anterior descending
artery are indicated with a
green tick mark.
Some views that may be
useful but are not generally
recommended are indicated
with an orange tick mark
and inadequate views with a
red cross.

143. LCx

144. RCA

145. The Routine

147. Chamber Views

148. LV ANGIOGRAM
Left ventriculography in diastole (A) and systole (B) taken in the right anterior oblique projection. A pigtail catheter is placed
into the left ventricular cavity and during acquisition 35 ml contrast is injected at 15 ml/sec via an automated injector.

149. RAO LAO
1, Basal
2, lateral
3, apical
4, septal
1, Anterior basal
2, anterior
3, apical
4, inferior
5, inferior basal

150. DEMO with 3D Anatomy ATLAS

152. What is skewed view?

153. What is panning?
• Vs zooming