The document describes coronary artery anatomy and angiographic views. It discusses the origins, courses, and branches of the left main, left anterior descending, circumflex, and right coronary arteries. It also covers coronary dominance, variations, angiographic projections used to visualize different coronary artery segments, and challenges of coronary angiography.

1. ANATOMY AND ANGIOGRAPHIC VIEWS
Coronary Arteries

2. ORIGINE
 Left coronary artery: arises from the left
coronary sinus/cusp of the Aortic valve
 Left main artery branches into:
 LAD- Left Anterior Descending
 CX- Circumflex
 Right coronary artery: arises from the right
coronary sinus/cusp of the Aortic valve

3. COURSE AND BRANCHES
 Coronary arteries lie on top of the
myocardium (epicardial) and follow the
Atrioventricular (AV) groove and the
Interventricular (IV) groove
 CX courses along AV groove
 LAD and distal RCA follow IV groove

4.  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.

5.  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).

6.  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.

8. CORONARY DOMINANCE
 A person can be “right dominant”, “left
dominant”, or “co-dominant”.
 This depends on which artery (or arteries)
give rise to the PDA and PLA, which run
along the posterior side of the heart

9. VARIATIONS AND ANOMALIES
 As with all structures in the human body,
WEIRD stuff can happen! A few examples:
 CX originates with RCA from right sinus
 LM from right sinus
 RCA from left sinus
 Separate originations (ostia) for all three
 All three arteries from one ostia

10. ANOMALIES
 Coronary aneurysms
 Fistulas- abnormal communication with
venous system
 Anomalous origin of LCA from Pulmonary
Artery

11. ANGIOGRAPHIC VIEWS-NOMENCLATURE
Image intensifier is directly over patient with beam
traveling perpendicularly back to front
AP position
Image intensifier is on right side of patient. A, anterior; O,
oblique
RAO position
Image intensifier is on left side of patientLAO position
Image intensifier rotated 90 degree parallel to floorLt Lateral position
Image intensifier is tilted toward head of patientCranial
Image intensifier is tilted toward feet of patientCaudal

13. CHALLENGES
The art of coronary angiography is to expose
the most by
 showing the least foreshortened coronary
artery segment
 at an angulation that causes the lowest
radiation to the operators
 and by the least number of radiographs
needed.

14.  Anatomic landmarks formed by the spine, catheter and
diaphragm provide information to define 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 left.
 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.

15. GUIDELINES FOR MOVING THE
IMAGE INTENSIFIER
 The first rule is that the left circumflex artery
(LCX) goes with the image intensifier and the
left anterior descending artery (LAD) goes in
the opposite direction.
 The second rule is that, in order to straighten
a very tortuous coronary segment, the image
intensifier should be moved to an angle that
is more or less 90° opposite to the current
one,

16. LEFT MAIN
 How to expose the LM, when the heart is
horizontal: LAO caudal view
 How to expose the LM, when the LM is
long and has a downward direction: LAO
cranial
 AP cranial and lateral views have no role in
imaging LM
 in case of left main disease: only two views
that show all the left system (LM, LAD, LCX)
needed for CABG: the AP caudal and AP
cranial views.

17. LEFT ANTERIOR DESCENDING ARTERY
 The LAO Cranial View :delineates clearly the
course of the LAD, from its origin to the apex,
and the correlation with its septals and
diagonals.The diagonals would be in the left
of the screen and the septals would come
out from the right of the LAD.
 However, in this view, the proximal LAD is
foreshortened.

18.  Exposure of the high diagonal: good
spider view with steep caudal angulation.
 The proximal LAD is defined as the segment
from the ostium to the origin of the first
septal. The distal end of the mid-segment is
less rigorously defined and is typically the
location where the LAD dips downward on an
RAO view.

19. LEFT CIRCUMFLEX ARTERY
 The proximal segment of the LCX starts from
the ostium up to and including the origin of the
first obtuse marginal (OM). The distal LCX is
beyond this point.
 standard RAO caudal view may provide much
needed information.
 In the case of mid- or distal LCX–OM
intervention, an RAO caudal view can
foreshorten the proximal LCX, LAO caudal
(spider) view would give a sharp delineation

20. RIGHT CORONARY ARTERY
 The proximal segment of the right coronary
artery (RCA) originates at the ostium and
ends after the first curve. The midsegment
ends at the second curve.
 In the LAO projection, the artery appears like
a letter C, whereas,
 in the RAO position, it appears like a letter L.

21.  To view the ostial segment of the RCA,
the best view is the LAO caudal view.
 To view the distal PDA, the LAO cranial
view coupled with deep inspiration,
 To view mid segment: best view is the
lateral view.