4. Clinical division of RCA
• Proximal - Ostium to 1st main RV branch
• Mid - 1st RV branch to acute marginal branch
• Distal - acute margin to crux
5. Clinical division of LAD
• Proximal - Ostium to 1st major septal
perforator
• Mid - 1st perforator to D2 (90 degree angle)
• Distal - D2 to end
6. Clinical division of the LCX
• Proximal - Ostium to 1st major obtuse
marginal branch
• Mid - OM1 to OM2
• Distal - OM2 to end
7. Normal calibre
• LMCA: 4.5 ± 0.5 mm
• LAD: 3.7 ± 0.4 mm
• LCX : 3.5 ± 0.5 mm ( 4.2 mm if dominant)
• RCA: 3.9 ± 0.6 mm ( 2.8 mm if non-dominant)
• LCA ostium ~ 4mm
• RCA ostium~ 3.2mm
8. Dominance
• Right-Dominant Circulation-85%
– RCA
• conus branch (supplies RVOT)
• AM(supply free wall of RV)
• AV nodal artery, PDA-PLV (supplies inf part of IVS)
• Left-Dominant Circulation- 8%,
– PD,PLV & AV nodal all supplied by terminal portion of
LCX
• Balanced-Dominant Circulation- 7%
– RCA- PD
– LCX- all PLV
9. What is significant CAD?
• >50% - significant disease
• >2 mm vessel only considered for
revscularisation
• >70% considered hemodynamically significant
ds
• >50% is considered in LMCA
11. Angiographic Views-Nomenclature
• AP position : Image intensifier is directly over patient
with beam traveling perpendicularly back to front (i.e.,
from posterior to anterior) to patient lying flat on x-ray
table
• RAO position : Image intensifier is on right side of
patient. A, anterior; O, oblique
• LAO position: Image intensifier is on left side of patient
• Lt Lateral position :Image intensifier rotated 90 deg
parallel to floor
• Cranial :Image intensifier is tilted toward head of
patient
• Caudal : Image intensifier is tilted toward feet of
patient
12.
13. Standard Angiographic Views
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
RIGHT
LAO view
Diaphragm
shadow
Cranial view
14.
15. LCA - AP caudal or shallow RAO
• LMCA -entire length
• Prox LAD & LCX (branches overlapped)
• After LM segment, slight RAO or LAO
Angulation may be necessary to clear density
of vertebrae /catheter shaft
16. LAO-cranial view
• LMCA (slightly foreshortened)
• LAD-Septal & diagonal are separated clearly
• LCX/OM: foreshortened/ overlapped
• PD/PL of left-dominant circulation are displayed clearly
• Deep inspiration helpful
• Cranial angulation permits view of LAD/LCX bifurcation
• LAO-cranial angulation that is too steep or inspiration
that is too shallow produces considerable overlapping
with diaphragm and liver, degrading the image
18. RAO-caudal
• LMCA bifurcation
• Origin & course of LCX/OM, RI & prox LAD
seen clearly
• One of the best for visualization of LCX
• LAD beyond proximal segment obscured
• Apical LAD displayed clearly
20. RAO-cranial
• Used for origins of diagonals along mid /distal
LAD
• Diagonals bifurcations well visualized
• Diagonals projected upward
• Prox LAD/LCX usually overlapped
24. Lateral view
• Best view to show mid & distal LAD
• LAD/LCX well separated
• Diagonals usually overlapped
• RI course well visualized
• It best shows insertions of bypass grafts into
mid LAD
25. RCA --- LAO-cranial
• Origin of RCA
• Entire length of mid RCA
• PDA bifurcation (crux)
• Cranial angulation tilts PDA down to see vessel
contour / reduce foreshortening
• Deep inspiration is necessary to clear
diaphragm
27. RCA - RAO view
• Shows mid RCA & length of PDA / PL
• Septals coursing upward from PDA, supplying
occluded LAD artery via collaterals, may be
clearly identified
• PL are overlapped, may need addition of
cranial view
35. 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
36. 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
37. 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
38. Standard Angiographic Views
Left Coronary Artery
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
39. Standard Angiographic Views
Left Coronary Artery
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
40. Standard Angiographic Views
Left Coronary Artery
PA0 Caudal 30
LM
LAD
Diagonal
Septals
Distal
LAD
LCx
LAO 50 Caudal 30
OM
LM
LAD
Diagonal
Distal
LAD
LCx
OM
‘Spider’ view
Best for visualization of LM
bifurcation and proximal LAD
and LCx
Best for visualization of LM
bifurcation, proximal LAD and LCx and
OM
41. Standard Angiographic Views
Right Coronary Artery
LAO 30
Proximal
RCA
PDA
Distal
RCA
Mid
RCA
RAO 30
Mid
RCA
PDA/
PLV
PA 0 Cranial 30
Proximal
RCA
PDA
Distal
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
42. 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
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
46.
47.
48. TIMI Frame count
Type of Frame Count How to perform Result
Unadjusted Frame Count
Subtract initial frame
from final frame number
Unadjusted Frame Count
= 28 - 8 = 20
20
Raw TIMI Frame Count
Adjust for filming speed.
Raw TIMI Frame Count =
20 * (30 fps)/(15 fps) = 40
40
Corrected TIMI Frame
Count
Correct for vessel length.
Corrected TIMI Frame
Count = 40 ÷ (1.6) = 25
25
Raw TFC TIMI Flow Grade
≤ 40 3
> 40 and ≤ 68 2.5
> 68 2
100 1
100 0
Infarct-Related
Artery
Correction Factor
LAD 1.7
SVG 1.6
RCA 1.0
LCx 1.0
