pci

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. 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. 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

6. 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

8. 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

9. 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)

10. Left anterior oblique view showing
normal RCA

11. Partial occlusion of RCA

12. 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

14. • 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)

15. 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

17. 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)

18. Right anterior oblique coronary
angiographic view showing LMCA, LAD
and LCX

19. Occlusion of LAD

20. Narrowing of LMCA

21. 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

22. 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

23. MYOCARDIAL BRIDGING

24. SHEPHARD’S CROOK CORONARY
ARTERY

25. 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

26. 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

27. 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

28. • Aorto ostial lesion
• Tortuisity of vessel

29. • Lesion length
• Presence of side branch
• Total occlusion
blunt stump
bridging collateral
• Trifurcation
• Bifurcation
• Side branch angulation

30. Bifurcation Trifurcation

31. Lesion length > 20mm

32. Diffuse disease
Thrombus

34. 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

35. 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

36. ENTERING THE OSTIUM

37. PERCUTANEOUS CORONARY
INTERVENTION

38. 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

39. 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

40. CABG

41. CABG
• ADVANTAGES
Wider applicability
Ability to achieve
complete
revascularisation
Favourable outcome in
diabetics
Effective in relieving
symptoms
• DISADVANTAGES
Cost
Morbidity
Patient preference

42. CORONARY VENOUS ANATOMY

44. 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

45. • 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)

47. 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

48. CORONARY VENOUS SEGMENTS

49. CRT

50. CRT

51. CORONARY SINUS CATHETER IN EP
STUDY

53. STEM CELL TRANSPLANT

55. 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.

56. Thank
you