Coronary angiography remains the gold standard for detecting coronary artery disease. The technique was first performed in 1958 and is used to visualize the coronary arteries and assess for stenosis. It can determine treatment options and prognosis. Complications are rare but include vascular injury and contrast reactions. Proper angiographic views are important for evaluating different coronary artery segments.

1. Dr Jain T Kallarakkal MD, DM (Cardiology)
Dr Biswajit Sahoo MBBS, PGDC (Cardiology)

2.  Coronary angiography remains the gold
standard for detecting clinically significant
atherosclerotic coronary artery disease
 The technique was first performed by Dr.
Mason Sones at the Cleveland Clinic in 1958

3.  To visualize coronary arteries, branches,
collaterals and anomalies
 Precise localization relative to major and
minor side branches, thrombi and areas of
calcification
 To visualize vessel bifurcations, origin of side
branches and specific lesion characteristics
(length, eccentricity, calcium etc)

4.  To rule out the presence of coronary stenosis,
define therapeutic options, and determine
prognosis.
 Used as a research tool for follow-up after
invasive procedures or pharmacologic
therapy.
 High-risk criteria include low ejection fraction
and poor exercise capacity on an exercise
test.

5.  In patients with non–ST-segment elevation
acute coronary syndromes with high-risk
features (e.g., ongoing ischemia, heart
failure)
 In
patients with acute ST-segment elevation
myocardial infarction (STEMI)
 Primary percutaneous intervention (PCI) is
usually performed in the same procedure,
immediately after the diagnostic procedure

6.  Coagulopathy
 Decompensated congestive heart failure
 Uncontrolled Hypertension
 CVA
 Refractory Arrythmia
 GI Haemorrhage
 Pregnancy
 Inability for patient cooperation
 Active infection
 Renal Failure
 Contrast medium allergy

7.  Major complications are uncommon (<1%)
 Vascular complications related to the arterial
puncture site
 Mortality risk is 0.1% or less.
 Allergic contrast reactions, worsening kidney
function, and cerebrovascular accidents are rare
 Ventricular fibrillation may be provoked by
contrast injection into conal branch of the right
coronary artery.
 Iatrogenic coronary artery dissection is a
potential life-threatening complication, which
usually is handled by either emergent coronary
artery stenting or bypass surgery.

8.  The left and right coronary cusp give rise to
their respective coronary arteries
 The major epicardial vessels are the left main
coronary artery that divides into the Left
anterior Descending artery and Left
Circumflex Artery, and the Right Coronary
artery.

11.  Coronary dominance is based on the vessel that
gives rise to the posterior descending artery
which supplies the Atrio-ventricular node.
 Recognized by the presence of septal perforating
branches, arises from the RCA in 80% from and
the LCx in 10% of the population.
 Co-Dominance is found in 10% of the population
where the posterior interventricular artery is
formed by both the RCA and LCx.

13.  The Left main coronary artery originates from
the left coronary cusp and bifurcates to give
rise to the Left anterior descending and Left
Circumflex arteries.
 Occasionally, a third branch vessel, the
Ramus Intermedius arises from the LMCA.
 In a small number of patients, the two major
branch vessels arise from separate origins.

14.  LAD provides blood supply to the anterior
wall of the left ventricle.
 It provides multiple septal branches to the
interventricular septum and diagonal
branches to the anterior lateral wall.
 The LAD in some patients wraps around the
apex to supply a small amount of the
posterior apex.

15.  LCx courses around the lateral or left atrio-
ventricular groove and gives rise to multiple
marginal or lateral branches. The branches are
termed obtuse marginal (OM) branches.
 OM branches are sequentially numbered (OM1,
OM2 etc…).
 As the LCx courses the AV groove it also gives
rise to several atrial branches, and occasionally
the sino-atrial branch (40% of the population).

16.  RCA arises from the right coronary cusp and
follows the right AV groove.
 The most proximal branches of the RCA are the
conus-branch which supplies the Right
ventricular outflow tract and a branch that
supplies the sino-atrial (SA) node (60% of
patients).
 RCA gives off the postero lateral and posterior
descending branches at the crux cordis

19.  Anatomic landmarks formed by the spine, catheter and
diaphragm provide information to discern which
tomographic view from which the image is obtained.
 In the LAO view the catheter and spine are seen on the
right side of the image, while in the RAO they are found on
the right.
 PA imaging places these landmarks in the center.
 Cranial can usually be distinguished from caudal
angulation by the presence of the diaphragm. For cranial
imaging, the patient should be asked to inspire to remove
the diaphragmatic shadow from the image.

20.  Generally, for circumflex and proximal
epicardial visualization the caudal views are
most useful.
 For LAD and LAD/diagonal bifurcation
visualization the cranial views are most
useful.

21.  Left Main AP, LAO cranial, LAO caudal
 Proximal LAD LAO cranial, RAO caudal
 Mid LAD LAO cranial, RAO cranial,
Lateral
 Distal LAD AP, RAO cranial, Lateral
 Diagonal LAO cranial, RAO cranial

22. Proximal circumflex RAO cranial, LAO caudal
Intermediate RAO caudal,LAO caudal
Obtuse marginal RAO caudal, LAO caudal, RAO
cranial
Proximal RCA LAO, Lateral
Mid RCA LAO, Lateral, RAO
Distal RCA LAO cranial, Lateral
PDA LAO cranial
Posterolateral LAO cranial, RAO cranial

34.  The severity or degree of stenosis is
measured by comparing the area of
narrowing to an adjacent normal
segment, and as a percentage
reduction and calculated in the
projection which demonstrates the
most severe narrowing.

35.  Normal distal runoff (TIMI 3)
 Good distal runoff (TIMI 2)
 Poor distal runoff (TIMI 1)
 Absence of distal runoff (TIMI 0)

36. Grade Collateral appearance
0 No collateral circulation
1 Very weak reopcification
2 Reopacified segment, less dense
than the feeding vessel and filling
slowly
3 Reopacified segment as dense as the
feeding vessel and filling rapidly

37.  LMCA originating from right sinus of Valsalva
 RCA originating from left sinus of Valsalva
 RCA originating above the sinus of Valsalva
or from anterior aortic wall
 LAD originating from right sinus of Valsalva
 LAD and LCx originating from separate ostia

38. Thank You