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NORMAL CORONARY ANATOMY AND ANGIOGRAPHIC VIEWS SOURCE.pptx
- 2. •Development of coronaries •Physiology of coronary circulation •Coronary artery anatomy TO BE DISCUSSED
- 4. •Open circulation heart coronary 2 coronaries •No invertebrates with hearts have coronaries EVOLUTION
- 6. ATRIA VENTRICLE HEART CHAMBERS CORONARY PISCES 1 1 2 0/1 AMPHIBIAN 2 1 3 1 REPTILES 2 1 3 1 AVES 2 2 4 1/2 MAMMALS 2 2 4 2
- 7. • Aquatic life to terrestrial • Gills to lungs • Blood to lungs • Erect posture • Increase in body mass and heart thickness • Deoxygenated blood in lumen of RV NEED FOR CORONARIES
- 8. DEVELOPMENT OF THE CORONARY ARTERIES – RETROGRADE CONNECTION David E. Reese et al. Circ Res. 2002;91:761-768 . PRO EPICARDIAL ORGAN
- 9. • Latin word “corona” means crown • 1st anatomical drawings- Leonardo da Vinci • Oblique inverted crown CORONARY TERMINOLOGY
- 10. • A coronary artery or its arterial branch is any vessel that carries blood to the cardiac parenchyma • Does not include the pericardium DEFINITION
- 11. • Dual aortic origin • RCA in right AV groove • LCA in left AV groove + anterior interventricular groove • PDA from RCA or LCx • Major vessels course epicardially • Arteries terminate in myocardial capillary bed TRIVELLATO criteria
- 12. • The name of a coronary artery or branch depends upon the vessel’s distal vascular territory, not by its origin • The different sinuses of Valsalva - identified not by the coronary arteries that originate from them but, rather, by their own topographic location NOMENCLATURE
- 13. • Each artery arises from respective aortic sinuses - Right coronary sinus - Left coronary sinus - Non-coronary sinus THE LEIDEN CONVENTION 1R;2L, Cx 2 1
- 14. • As coronary traverse distally – diameter decreases • Course is mainly epicardial • Normally terminate in capillaries • Anastomotic communications at the base and the apex of the left ventricle.
- 15. Vessel Mean diameter (mm) Left main 4 LAD 3.6 LCx 3.0 RCA 3.2
- 18. Blood flow Ml/min/100 gm (% CO) O2 consumption Ml/min/100 gm A-V O2 diff Ml/dl Coronary 70 (5%) 8.4 12.5 Cerebral 50 (15%) 3.3 6.7 Splanchnic 50 (25%) 2.1 4.2 Renal 400 (22%) 5.5 1.4 Cutaneous 10 (8%) 0.1 1.2 Muscular 2 (17%) 0.2 7.1 OXYGEN EXTRACTION
- 21. • Proximal - Ostium to 1st main RV branch • Mid - 1st RV branch to acute marginal branch • Distal - acute margin to the crux SURGICAL DIVISIONS OF THE RCA
- 22. • 90% single 10% double • 60% from RCA • Runs cranially, dorsally and to the right • Penetrates IAS bifurcates at SVC or encircles it clockwise or anti clockwise • Divides into two rami, one recurrent branch which supplies the SA node, the other runs posteriorly as a left atrial branch. 1. SINUS NODE ARTERY
- 23. - Separate ostium in 23% - 51% - Curves away from main artery and proceeds ventrally encircling the outflow tract of RV at the level of pulmonary valve. 2. CONUS ARTERY/ INFUNDIBULAR/ THIRD CORONARY/ARTERIA OF VIEUSSENS (1ST BRANCH IN 60% CASES)
- 25. - Arising in the AV groove 3. RIGHT ATRIAL BRANCHES - Originates at the level of acute marginal artery travels in opposite direction towards right heart border 4. RIGHT VENTRICULAR BRANCHES Large and constant vessel Arises at lower aspect of right atrium just before or at the acute margin of the heart. 5. ACUTE MARGINAL ARTERY
- 26. 6. AV NODAL ARTERY
- 27. 7. Posterior descending artery • Posterior interventricular groove • Small inferior septal branches which supply lower part of IVS and interdigitate with superior septal branches from LAD. • Decides dominance 8. Posterolateral branches • RCA continues as the posterolateral branch to supply the diaphragmatic surface of the LV. TERMINAL BRANCHES
- 28. • 0-40 mm • Horizontal due to oblique lie of heart • Retropulmonary segment • Sterno costal segment if present-long LM • Trifurcates in 1/3rd : Ramus intermedius/ median artery/ left diagonal artery/straight LV artery LEFT MAIN
- 29. • Proximal - Bifurcation to 1st major septal perforator or 1st diagonal artery whichever is first • Mid - 1st perforator to D2 • Distal - D2 to end SURGICAL DIVISIONS OF THE LAD
- 30. • Diagonals 2-9 for LV free wall • 4-6 Perforating septals 70-80 mm in length (septals from PDA are <15 mm) • Left conal artery BRANCHES OF LAD
- 31. • By D.B.Effler • Based on length and amount of myocardium it perfuses • Type 1 : Falls short of Apex • Type 2 : Reach up to the LV apex • Type 3 : Wraps around LV apex and travels some distance in the posterior Inter- ventricular groove. LAD –ANGIOGRAPHIC CLASSIFICATION
- 32. • Proximal - Bifurcation to 1st major obtuse marginal branch • Mid - OM1 to OM2 • Distal - OM2 to end SURGICAL DIVISIONS OF THE LCX
- 33. - ~9 cm long - Left atrial branches - Kugel’s artery (Arteria anastomotica auricularis magna) - LV branches are called the Obtuse marginal arteries LEFT CIRCUMFLEX ARTERY
- 34. • Origin of PD artery • Right in 85% • Left 5% • Balanced in 10% DOMINANCE
- 35. • Major coronary arteries form a circle and a loop around the heart. • Circle : RCA & Left Cx in AV sulcus. • Loop : LAD & PDA in interventricular groove at right angles from circle CIRCLE AND LOOP THEORY
- 36. • Antero-lateral- LAD and LCX • Posteromedial- Either from RCA or LCX • SA node - RCA 55% & LCA 45% • AV node- RCA 90% & LCA 10% PAPILLARY MUSCLES/NODES
- 37. • Bundle of His – • AV nodal artery • First Septal from LAD • RBB- septal perforators from LAD and PDA • LBB- • Anterior- LAD septal perforator • Posterior- PDA septal perforator • Purkinje fibres- LAD septal perforator CONDUCTION SYSTEM
- 38. • Aortic and pulmonary valve- no blood supply • Mitral valve- left atrial branch from LCX • Tricuspid- Rt atrial branches from RCA ARTERIAL SUPPLY OF VALVES
- 40. •Large veins from LV CS RA •Small veins from 2/3 RV RA •Smallest veins from RA/RV RA/RV CORONARY VENOUS SYSTEM
- 41. GREAT CARDIAC VEIN AND LAD
- 42. OBLIQUE VEIN OF LA
- 43. • Great cardiac vein • Obtuse marginal vein • Posterolateral vein • Middle cardiac vein • Oblique vein of LA Tributaries of CS
- 45. CORONARY ANGIOGRAPHY Introduction Angiography: Visualisation of the vascular bed via X- ray with contrast injection Types: • Conventional • CT • MRA Conventional CAG: Current gold standard
- 46. HISTORY • Egas Moniz: Cerebral angiography 1927 • Werner Forssmann: Cardiac Catheterization 1929 • André Frédéric Cournand and Dickinson Richards: Catheterisation and hemodynamics 1940
- 47. WERNER THEODOR OTTO FORSSMANN • The Nobel Prize in Physiology or Medicine 1956
- 48. INDICATIONS • Established CAD: To define coronary anatomy and formulate management plan Emergent revascularization in STEMI • To confirm non invasive diagnosis of CAD • Left ventricular dysfunction, ventricular arrhythmias, ambiguous non invasive test results. • Pre Surgical evaluation
- 49. CONTRAINDICATIONS • No absolute contraindications • Anemia • Renal dysfunction • Active infection • High bleeding risk • Contrast Allergy
- 50. EQUIPMENT • CARDIAC CATHETERISATION LABORATORY
- 52. ACCESS SITES • Femoral • Most frequently used access site • Ease of access, lesser contrast and radiation exposure, freedom to upgrade to bigger size sheaths. • Need for immobilization, local site complications: main drawbacks • Radial • No need for immobilisation • Lower rate of local vascular complications • Increasingly being used as primary access site • Slightly higher contrast and radiation exposure with beginners • Spasm, loops, failure to get access may require switch to femoral route
- 53. ACCESS - SELDINGER TECHNIQUE • Sven-Ivar Seldinger (1921- 1998) Swedish Radiologist.
- 54. OTHER ACCESS SITES • Brachial • Ulnar • Radial in Anatomical Snuff Box
- 55. CONTRAST MATERIAL High osmolality ionic contrast media: • Not used nowadays • High incidence of adverse events Low osmolar non ionic contrast agents: • Most commonly used agent Well tolerated -IOHEXOL • Iso osmolar non ionic contrast agents - IODIXANOL
- 56. CONTRAST INJECTION Left coronary artery: 6-8ml over 2-3 seconds Right coronary artery: 4-6ml over 2-3 seconds • Should be adequate to fill the coronary artery completely without streaming • Excessive contrast injection should be avoided • Cine acquisition (@10fps) should continue till contrast clears from the system
- 68. LEFT CORONARY ARTERY ANGIOGRAM LAO 50 Caudal 25 Spider view LCX RAMUS
- 69. LEFT CORONARY ARTERY ANGIOGRAM LAO 20 cranial 25 LCX
- 70. LEFT CORONARY ARTERY ANGIOGRAM Caudal 40 LCX
- 71. RIGHT CORONARY ARTERY ANGIOGRAM LAO 45 PLV PDA
- 72. RIGHT CORONARY ARTERY ANGIOGRAM RAO 30 PLV PDA
- 73. RIGHT CORONARY ARTERY ANGIOGRAM LAO 20 cranial 25 PLV PDA
- 74. OPTIMAL VIEWS OF THE LEFT CORONARY ARTERY RAO Caudal
- 75. OPTIMAL VIEWS OF THE LEFT CORONARY ARTERY – RAO CRANIAL RAO Cranial
- 76. OPTIMAL VIEWS OF THE LEFT CORONARY ARTERY – LAO CRANIAL LAO Cranial
- 77. OPTIMAL VIEWS OF THE LEFT CORONARY ARTERY – LAO CAUDAL LAO Caudal
- 78. OPTIMAL VIEWS OF THE RIGHT CORONARY ARTERY - PROXIMAL RCA LAO 30
- 79. OPTIMAL VIEWS OF THE RIGHT CORONARY ARTERY - BIFURCATION OF THE RCA LAO 10 Cranial 20
- 80. OPTIMAL VIEWS OF THE RIGHT CORONARY ARTERY - MID RCA RAO 30
- 81. • Superficial or deep • LAD • Milking effect • Complicate CABG • Higher incidence and poorer prognosis in HOCM MUSCULAR BRIDGES
- 82. Michel T. Corban et al. JACC 2014;63:2346-2355 American College of Cardiology Foundation
- 83. STENOSIS
- 84. CALCIFICATION
- 85. THROMBUS
- 86. TORTUOSITY Two or more consecutive 180° turns in a major epicardial artery
- 87. DISSECTION
- 88. FLOW TIMI (THROMBOLYSIS IN MYOCARDIAL INFARCTION) FLOW GRADE
- 89. COMPLICATIONS • Local: • Bleeding • Hematoma • Infection • Pseudoaneurysm • Compartment Syndrome • Coronary • Dissection, embolism, spasm • Contrast related • Contrast nephropathy • Allergic reactions • Arrhythmias • Access vessel dissection • Stroke • Death
- 90. OTHER CORONARY IMAGING MODALITIES • CTA : Accurate, noninvasive alternative; 3D Reconstruction; Screening. • MRA : Non Invasive, Radiation Free; analysis of cardiac function, cardiac anatomy, viability and perfusion • IVUS : 4 to 6 weeks and 1-year post cardiac transplantation to rule out donor CAD ; determination of the mechanism of stent thrombosis • OCT (Optical Coherence Tomography) 10-fold higher resolution than IVUS; can differentiate tissue characteristics (fibrous, calcified, or lipid-rich plaque) and identify thin-cap fibroatheroma • Angioscopy : full-color, 3-dimensional perspective of the intracoronary surface morphology
- 91. THANK YOU
- 103. MYOCARDIAL BRIDGE
- 115. 0 Diastole 1 Isovolumetric contraction 2 Rapid ejection 3 Slow ejection 4 Isovolumetric relaxation Phasic coronary flow
- 116. • Advantages • CAD • AR • Surgery not interrupted • deairing • Disadvantages • Veno-venous shunts • Thebasian veins • RV inadequately protected • Difficult to place • Missed LSVC bath CS with warm blood Retrograde CPG cannula
- 117. DOSE & RATE FOR CARDIOPLEGIA • Dose : 20 ml / kg • Rate of flow : 150 ml /m2 / min • Pressure Antegrade root : 80-150 mm Hg ostial: left 100-120 mm Hg right 90 -100 mm Hg retrograde : 40 – 50 mm Hg • High venous pressure (>50) may cause myocardial edema
- 118. •Normal variants relatively unusual but found in >1% of that population • Anomalies morphologic feature seen in <1% of that population VARIANTS AND ANOMALIES
- 119. Anomalies of origin High take off Single coronary Multiple ostia Origin from systemic connection ALCAPA Origin and course From opposite sinus Course b/w great vessels course Myocardial bridge Duplication of arteries termination Coronary fistulae Coronary arcade
Editor's Notes
- We will start by discussing the development of coronaries, followed by the physiology of coronary circulation and then the normal coronary artery anatomy.
- The phylum chordata (animals with backbones) is divided into five common classes: fish, amphibians, reptiles, mammals and birds All vertebrates share the common characteristic of having a backbone or spinal column, which provides support and protection for the nervous system.
- From Open circulation the need of a heart evolved and further down the line, as the heart evolved, so did the need to have a coronary system, eventually leading to the 2 coronary system seen in vertebrates. No invertebrates with hearts have coronaries
- A single circulatory system exists in all fish. Blood travels from the heart to the gills, where the gas exchange occurs only once, completing a full circuit in the fish's body. Incomplete double circulation is a process of circulation of blood in amphibians and reptiles. The right and left atrium receive deoxygenated and oxygenated blood respectively. Then the blood gets mixed up in the single ventricle. Double circulation supports a strict separation of both oxygenated and deoxygenated blood. Therefore, this circulation ensures that the body always has a dedicated supply of oxygen. This is also one of the reasons why mammals can maintain their body temperatures.
- To summarize, the number of atria and ventricles among different classes of vertebrates, where mammals finally evolved to have 2 separate atria and ventricles and 2 separate coronaries.
- Why did the need for coronaries arise? As life evolved from aquatic to terrestrial. Transition from Gills to Lungs was needed A second chamber to pump blood to the lungs was needed. Also posture change to erect had to be reconciled with The increase in body mass and heart thickness And Deoxygenated blood in the lumen of RV; all caused the coronaries to develop.
- Development of the coronary arteries. Movement of the Pro Epicardial Organ to and over the heart is shown in the top panel, and mesenchymal migration and differentiation are shown in the bottom panel. The Pro Epicardial Organ (blue) is seen as an outgrowth from the dorsal body wall that moves to the looping heart. Next, migrating epithelium is seen spreading over the heart. In cross section, the epithelium is seen as a single cell layer. Epithelial/mesenchymal transition provides cells that migrate into the myocardium. Vasculogenic cells differentiate and link to form folds that induce other mesenchymal cells to become smooth muscle. These folds are remodeled into definitive arteries, and the most proximal points of the major coronaries finally link up with the aorta.
- The term Coronary is derived form the Latin Word CORONA which means crown. 1st described by Leonardo Da Vinci in his anatomical drawings. System is shaped like an oblique inverted crown.
- By Definition, A coronary artery or its arterial branch is any vessel that carries blood to the cardiac parenchyma Does not include the pericardium
- 1980 Mario Trivellato laid down criterias for normal coronaries. Minimal requirements for normality include the following criteria: Dual aortic origin RCA in right AV groove LCA in left AV groove + anterior interventricular groove PDA from RCA or LCx Major vessels course epicardially Arteries terminate in myocardial capillary bed
- The name of a coronary artery or branch depends upon the vessel’s distal vascular territory, not by its origin The different sinuses of Valsalva - identified not by the coronary arteries that originate from them but, rather, by their own topographic location
- Which brings us to the Leiden Convention where The observer is located in the non coronary sinus and is looking toward the pulmonary trunk. Of the sinuses adjacent to the pulmonary trunk, one is thus to the left hand side. This is sinus no. 2. The other sinus, to the right-hand side, is sinus no. 1. In the usual arrangement, the right coronary artery arises from sinus no. 1, and the main stem of the left coronary artery from sinus no. 2.
- As coronary traverse distally – diameter decreases Course is mainly epicardial Normally terminate in capillaries There exists Anastomotic communications between its different branches, particularly at the base and the apex of the left ventricle.
- The mean diameters of Each major coronary are Left main 4mm Left Anterior Descending : 3.6 mm Left Circumflex : 3 mm And the Right Coronary Artery : 3.2 mm
- The coronary arteries and their major branches are sub-epicardially located
- Histology The Tunica Intima, besides being the innermost layer supporting the endothelial cells has a secretory function as well. Tunica Intima-prostacyclin, vWF, IL-1, PDGF and has receptors for LDL and thrombin Tunica media – more muscle less elastin Tunica adventitia – longitudinal loose collagen to allow coronary calibre changes
- Compared to most organs of the body, the oxygen extraction of the heart is relatively high. The oxygen extraction of the heart is typically 2-3 times more than that of the brain.
- Regulation of coronary blood flow is understood to be dictated through multiple mechanisms including extravascular compressive forces (tissue pressure), coronary perfusion pressure, myogenic, local metabolic, endothelial as well as neural and hormonal influences. Together, these mechanisms govern coronary flow and act to ensure an overall balance between myocardial oxygen delivery (supply) and metabolism (demand)
- Proximal - Ostium to 1st main RV branch Mid - 1st RV branch to acute marginal branch Distal - acute margin to the crux
- 90% single 10% double 60% arises from RCA Runs cranially, dorsally and to the right Penetrates IAS bifurcates at SVC or encircles it clockwise or anti clockwise Divides into two rami, one recurrent branch which supplies the SA node, the other runs posteriorly as a left atrial branch.
- Separate ostium in 23% - 51% Curves away from main artery and proceeds ventrally encircling the outflow tract of RV at the level of pulmonary valve.
- Location of conotruncal anastomotic collateral rings Vieussens' arterial ring (VAR) refers to the connection between the conus artery and the left anterior descending (LAD) coronary artery's proximal right ventricular branch
- Usually supplied by dominant coronary Origin from characteristic U turn of RCA near crux Also supplies BOH
- 7. Posterior descending artery Located in the Posterior interventricular groove Consists of Small inferior septal branches which supply lower part of IVS and interdigitate with superior septal branches from LAD. Decides dominance 8. Posterolateral branches After giving rise to PDA ,the RCA continues as the posterolateral branch to supply the diaphragmatic surface of the LV.
- 0-40 mm Horizontal due to oblique lie of heart Lies behind the pulmonary artery Sterno costal segment if present-long LM Trifurcates in 1/3rd : Ramus intermedius/ median artery/ left diagonal artery/straight LV artery
- Proximal - Bifurcation to 1st major septal perforator or 1st diagonal artery whichever is first Mid - 1st perforator to D2 Distal - D2 to end
- Diagonals 2-9 for LV free wall 4-6 Perforating septals 70-80 mm in length (septals from PDA are <15 mm)- Left conal artery
- By D.B.Effler Based on length and amount of myocardium it perfuses Type 1-small caliber vessel reaches only 2/3rd of way from base of heart to apex, more prevalent in women Type 2-larger caliber reaches the apex of LV Type 3-extends from base to apex wraps around the diaphragmatic surface of LV where it augments the perfusion pattern of PDA.
- Proximal - Bifurcation to 1st major obtuse marginal branch Mid - OM1 to OM2 Distal - OM2 to end
- ~9 cm long Left atrial branches Kugel’s artery (Arteria anastomotica auricularis magna) LV branches are called the Obtuse marginal arteries
- Origin of PD artery Right in 85% Left 5% Balanced in 10%
- The circle and half loop model has been introduced to illustrate the anatomic relationships among these arteries. The circle consists of the RCA and the LCx arteries Whereas the half loop is formed by the LAD artery and the posterior descending artery.
- Antero-lateral- LAD and LCX Posteromedial- Either from RCA or LCX SA node - RCA 55% & LCA 45% AV node- RCA 90% & LCA 10%
- Bundle of His – AV nodal artery First Septal from LAD RBB- septal perforators from LAD and PDA LBB- Anterior- LAD septal perforator Posterior- PDA septal perforator Purkinje fibres- LAD septal perforator
- Aortic and pulmonary valve- no blood supply Mitral valve- left atrial branch from LCX Tricuspid- Rt atrial branches from RCA
- Blood supply of the ventricular septum. Most of the septum is supplied by the left anterior descending coronary artery via large septal arteries. Septal arteries from the posterior descending artery are relatively small.
- Large veins from LV CS RA Small veins from 2/3 RV RA Smallest veins from RA/RV RA/RV (also called Thebesian veins and foramina venarum minimarum best seen at IAS)
- Great cardiac vein may run to the left, right or directly above LAD esp if LAD is intramural leading to difficulty in exposure of LAD. GCV runs lateral to PA and is covered by LAA.
- Marks junction of GCV and CS 95% population; 1 mm diameter Runs b/w LIPV and LAA Persists as LSVC
- Great cardiac vein Obtuse marginal vein Posterolateral vein Middle cardiac vein Oblique vein of LA Coronary sinus venogram – non homogenous distribution of retrograde cardioplegia only in left ventricular area
- Angiography: Visualisation of the vascular bed via X- ray/MRI with contrast injection Types: Conventional CT MRA Conventional CAG: Current gold standard
- • Egas Moniz: Cerebral angiography 1927 • Werner Forssmann: Cardiac Catheterization 1929 • André Frédéric Cournand and Dickinson Richards: Catheterisation and hemodynamics 1940
- In 1929 Werner Forssmann saw a picture in a book showing how a tube was inserted into the heart of a horse through a vein. Forssmann was convinced that a similar experiment could be carried out on people. Despite the fact that his boss forbade him, Forssmann conducted the experiment on himself. This he did by inserting a cannula into his own antecubital vein, through which he passed a catheter for 65 cm and then walked to the X-ray department, where a photograph was taken of the catheter lying in his right atrium. The experiment paved the way for many types of heart studies.
- • Established CAD: To define coronary anatomy and formulate management plan Emergent revascularization in STEMI • To confirm non invasive diagnosis of CAD Left ventricular dysfunction, ventricular arrhythmias, ambiguous non invasive test results. • Pre Surgical evaluation
- No absolute contraindications Anemia Renal dysfunction Active infection High bleeding risk Contrast Allergy
- Femoral Most frequently used access site Ease of access, lesser contrast and radiation exposure, freedom to upgrade to bigger size sheaths. Need for immobilization, local site complications: main drawbacks Radial No need for immobilisation Lower rate of local vascular complications Increasingly being used as primary access site Slightly higher contrast and radiation exposure with beginners Radial artery Spasm, loops, failure to get access may require switch to femoral route are the major drawbacks
- The Seldinger technique is named after Swedish radiologist Sven-Ivar Seldinger, who develop ed the procedure in the 1950s. The procedure involves making a small incision in the skin and using a guidewire to thread a catheter, a thin, flexible tube, into the target blood vessel
- Brachial Ulnar Radial in Anatomical Snuff Box
- High osmolality ionic contrast media: • Not used nowadays • High incidence of adverse events Low osmolar non ionic contrast agents: • Most commonly used agent IOHEXOL Well tolerated • Iso osmolar non ionic contrast agents IODIXANOL
- Left coronary artery: 6-8ml over 2-3 seconds Right coronary artery: 4-6ml over 2-3 seconds • Should be adequate to fill the coronary artery completely without streaming • Excessive contrast injection should be avoided • Cine acquisition (@10fps) should continue till contrast clears from the system
- let's take a moment to look at how we acquire an angiographic image and also discuss some of the terminology that we use. Like any procedure that involves ionizing radiation we need an x-ray source which emits x-rays and is detected on an image intensifier. In the cath lab the x-ray source and the image intensifier are connected together by this structure we call a C arm because it looks like a letter C
- we then position the patient with the x-ray beam centering on the heart.
- the C arms are then able to move around the patient in a number of different directions or planes to take different angiographic views. These are described in two anatomical planes.
- the first plane here shows the plane whilst looking from the patient's feet towards the patient's head. the second anatomical frame we're going to look at the patient from the side on position.
- starting with the first anatomical plane looking from the feet of the patient towards the patient's head. if the x-ray source is situated directly below the patient with the image intensifier directly above the patient this is referred to as a standard starting position or zero degrees. You can see that the image intensifier can then rotate around the patient towards the right known as the right anterior oblique or RAO view. Image intensifier can also rotate to the left known as the left anterior oblique or LAO. As you can see from the diagram the image intensifier can rotate right around to 90 degrees in either a right or a left direction if it rotates over here to 90 degrees it's known as a right lateral if it rotates over here to 90 degrees it's known as a left lateral
- here are two examples we can see that in this picture the image intensifier has rotated 30 degrees to the right and so we named this RAO 30. In the Second image the image intensifier has rotated 40 degrees to the left of the patient we note that as LAO 40
- Moving on to the second plane we can now see that the image intensifier can move towards the head of the patient known as a cranial angulation or towards the feet of the patient known as a caudal angulation There's a physical limitation here that isn't apparent in the other plane All modern image intensifier devices are fitted with proximity monitors these are essentially devices to ensure that the machine does not collide with a patient to cause injury. As you can see in the diagram there is a limit to how far the image intensifier can move in a cranial direction before it comes into contact with the patient similarly there is a limitation to how much the image intensifier can move in the caudal position for the same reasons.
- looking at two example images, on the first image again we can see the image intensifier has moved 30 degrees angulated towards the head of the patient this is described as cranial 30 degrees or cranial 30 for short And in the second image the image intensifier has been angled 20 degrees towards the feet of the patient which is described as caudal 20 degrees or caudal 20 for short
- let's look at a common angiographic view the LAO cranial view. We now know from previous slides that this means that the image intensifier must be towards the left of the patient in one anatomical plane LAO and that in the other anatomical plane it must be towards the head of the patient cranial. what we don't know is the specifics of how much it's moved in either of these different angulations in either plane
- it's very important to know exactly where the image has been acquired from in terms of the angulations so that it can be reproduced. if we now add an angulation to both of the different planes and change LAO cranial into LAO 40 degrees and cranial 25 degrees we can quite clearly understand now the image intensifier is 40 degrees to the left hand side of the patient LAO 40 and 25 degrees towards the head of the patient cranial 25
- LAO 50 caudal 25 (spider view) LMCA Best seen in a LAO projection with caudal angulation.
- LAO 20 cranial 25 No single view adequately depicts the entire course of the LAD. • LAO 20 cranial 25 Separates the Septals out from the diagonals. The proximal LAD is best visualized in LAO projections with cranial angulation, whereas the middle and distal segments are better seen in LAO and RAO views with some caudal angulation.
- Caudal 40 (AP 0) LCX The LCX is best seen in caudal projections. The proximal portion of the LCX is usually imaged in the RAO caudal angulation, which also lays out the marginal arteries.
- LAO 45 Best For Proximal and mid-RCA Ostium – LAO 50;
- RAO 30 Best for visualizing Mid-RCA, PDA collateral vessels to LAD
- LAO 20 cranial 25 Best for Distal RCA, bifurcation and PDA
- Right Anterior Oblique (RAO) Caudal The RAO caudal view is considered as the best view for the initial injection of the left system. RAO caudal view is also the best overall view to assess the myocardial perfusion or blush of the left circumflex territory.
- Right Anterior Oblique (RAO) Cranial The RAO cranial view clearly lays out the middle and distal segments of the left anterior descending artery as well as the origins of the diagonals.
- Left Anterior Oblique (LAO) Cranial The LAO cranial view provides a clear view of the middle and distal segments of the left anterior descending artery and the origins of the diagonals. It also exposes the ostium of the left main coronary artery.
- Left Anterior Oblique (LAO) Caudal The LAO caudal view or the 'spider view’ offers visualization of the left main coronary artery and the proximal segments of the left anterior descending artery, the ramus intermedius, and the left circumflex artery.
- Proximal RCA The Proximal RCA (R1 segment) including the ostium is best visualized in the 30° LAO view with no cranial or caudal angulation.
- Bifurcation of Distal RCA – Right posterolateral artery and posterior descending artery is best seen in LAO 10 Cranial 15-20 –
- The middle RCA is best visualized in the 30° RAO straight view.
- Superficial or deep Most common in LAD Milking effect in systole myocardial ischaemia Complicate CABG Higher incidence and poorer prognosis in HOCM
- “Milking Effect” in Coronary Angiography (A) Systolic compression of myocardial bridges: the “milking effect.” (B) Subsequent increase in vessel lumen diameter during diastole. White arrows indicate areas of myocardial bridging.
- Relationship of coronary artery stenosis in diameter and cross-sectional area. Diameter loss is represented by a side-on view of the artery on the left, the same degree of narrowing being shown in cross section on the right The estimate of the severity of stenosis is expressed as a percentage cross-sectional area loss
- The coronary angiogram is fairly insensitive to the presence of lesion calcification, particularly to the presence of deep vessel wall calcification. Intravascular ultrasound is much more sensitive in the assessment of vessel wall calcification.
- The coronary artery thrombus may be defined as an occlusion or blockage of blood flow within a vessel due to a clot.
- Coronary tortuosity is conventionally defined as two or more consecutive 180° turns in a major epicardial artery assessed by visual estimation.
- coronary artery dissection refers to a tear in the intimal layer that produces a pathognomonic appearance on coronary angiography i.e., dye staining, multiple radiolucent lumens, visualization of an intimal flap
- TIMI myocardial perfusion (TMP) grades Flow • TIMI grade: • TIMI 0 flow (no perfusion) refers to the absence of any antegrade flow beyond a coronary occlusion. • TIMI 1 flow (penetration without perfusion) is faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed. • TIMI 2 flow (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of the distal territory. • TIMI 3 is normal flow which fills the distal coronary bed completely
- • CTA : Accurate, noninvasive alternative; 3D Reconstruction; Screening. • MRA : Non Invasive, Radiation Free; analysis of cardiac function, cardiac anatomy, viability and perfusion • IVUS : 4 to 6 weeks and 1-year post cardiac transplantation to rule out donor CAD ; determination of the mechanism of stent thrombosis • OCT (Optical Coherence Tomography) 10-fold higher resolution than IVUS; can differentiate tissue characteristics (fibrous, calcified, or lipid-rich plaque) and identify thin-cap fibroatheroma • Angioscopy : full-color, 3-dimensional perspective of the intracoronary surface morphology
- Angiographic projections for coronary angiography procedure.
- The main coronary arteries may be considered to be located in two planes: the plane of the atrioventricular groove and the plane of the interventricular septum[13]. The right coronary artery (RCA) originates in the right sinus of Valsalva and runs in the right ventricular side of the atrioventricular groove.. If the RCA continues after the RDP to supply a portion of the posterior left ventricular wall (RPL), it is called a right dominant circulation (85% of people). If the LCA supplies the posterior left ventricular wall (LPL) the coronary circulation is called left dominant (5%), in 10% of people there is balanced system. The RDP runs in the posterior interventricular groove. In 60% the sinus node artery arises from the proximal portion of the RCA. The left main coronary artery (LMCA) originated in the left sinus of Valsalva. Its length varies from 5-10mm. Sporadically the LMCA is absent, resulting in separated ostia of RCx and LAD. Sometimes there is a trifurcation, with a branch between the RCx and LAD called intermediate artery. Usually the LAD runs in the anterior interventricular groove. The most important side branches are the septal branches and diagonal branches to the left ventricular wall. The RCx runs in the left atrioventricular groove. All branches to the left ventricular wall are classified as obtuse marginal or posterolateral branches. In 40% the sinus node artery arises from the proximal portion of the RCx.
- Coronary angiography in the right caudal view demonstrating a severe concentric stenosis in the left circumflex artery (*). Optical coherence tomography of the lesion demonstrates severe luminal narrowing with small tissue mass protruding into the lumen consistent with thrombus (A). Distal to the lesion, the left circumflex artery is seen to contain two distinct plaque types: (A) fibrous plaque is seen with a homogeneous and bright appearance (B) lipid-rich plaque with poorly reflective regions and diffuse margins with a thin bright fibrous cap consistent with thin-cap fibroatheroma.
- fibrous (green), calcific (white), necrotic core (red) and fibrofatty (green/yellow).
- Muscle overlying the intramyocardial segment of an epicardial coronary artery, first mentioned by Reyman1 in 1737, is termed a myocardial bridge, and the artery coursing within the myocardium is called a tunneled artery (Figure 1). It is characterized by systolic compression of the tunneled segment, which remains clinically silent in the vast majority of cases.
- Derivation of the coronary sinus and related structures. 1 and 7= right and left anterior cardinal veins; 2 and 8= posterior cardinal veins; 3 and 6 = common cardinal veins; 4 and 5= right and left horns of sinus venosus; 9 = right vitelline vein. The fate of these structures is shown in (B) la + 3a = superior vena cava; 2a = terminal part of the azygos vein; 4a = part of right atrium; 5a and proximal half of 6a= coronary sinus; distal half of 6a = oblique vein of left atrium; 7a + 8a = left superior intercostal vein; 9a = inferior vena cava.
- Proximity of right ventricular drainage to coronary sinus opening