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Nikolaos Konstantinidis
1st
Cardiology Department,
AHEPA University Hospital
Thessaloniki
Coronary angiography, coronary anatomy, anatomic variants, angiographic views and interpretation of
collected data
Innovations in Interventional Cardiology and ElectrophysiologyThessaloniki, 10-12 September 2015
Aristotle Universityof Thessaloniki
A’ Cardiology DepartmentAHEPA University Hospital
Coronary artery anatomy
Normal Features of the Coronary Anatomy in Humans
Paolo Angelini Circulation. 2007;115:1296-1305
Coronary artery anatomy
In relation to the heart
Coronary artery anatomy
In relation to the cardiac valves
Coronary artery anatomy
AHA coronary segments modified
Right Coronary Artery
• OriginRight aortic sinus (lower origin than LCA)
• CourseDown right AV groove toward crux of the heart, gives off PDA (85-90%) from which septals arise, continues in LAV groove giving off posterior LV branches (posterolaterals). PDA may originate more proximally, bifurcate early or be small with part of “its territory” supplied by an acute marginal branch.
• Supplies25% to 35% of Left Ventricle
• Conus ArteryUsually very proximal; (~50% have a separate origin)-courses anteriorly and upward over the RV outflow tract toward the LAD. May be an important source of collaterals.
• SA Nodal Artery(~60%) usually 2nd branch of RCA-courses obliquely backward through upper portion of atrial septum and anteromedial wall of the RA-supplies SA node, usually RA and sometimes LA.
Right Coronary ArteryBasic branches
Right Coronary Artery
• Right Ventricular and Acute Marginal BranchesArise from mid RCA; supply anterior RV; may be a collateral source
• AV Nodal ArteryArises at or near crux; supplies AV node
• PDASupplies inferior wall, ventricular septum, posteromedial papillary muscle.
Basic branches
Catheter armamentarium
Angiographic views, labeling
Right Coronary ArteryOptimal angiographic views
The lateral view is more helpful for -intubating the RCA and assessment of the mid segment
Cranial angulation (30°) of the left anterior or AP view useful for assessment of the crux cordis or the ostia of the PDA and posterolateralbranches.
A multipurpose catheter should be used for downward-looking RCAs, and Amplatz right 2 or Amplatz left 1 or 2 are required in patients with a high take-off and/or with dilatation of the coronary sinus and ascending aorta
Right Coronary ArteryOptimal angiographic views
Naber et al, Eurointervention 2010
Right Coronary ArteryOptimal angiographic views
Naber et al, Eurointervention 2010
Right Coronary ArteryOptimal angiographic views
LAO 40 LAO 20, CRANIAL 20
Right Coronary ArteryOptimal angiographic views
RAO 30, CRANIAL 15
Right Coronary ArteryOptimal angiographic views
LAO 40 LAO 40
Left Coronary Artery
• OriginUpper portion of left aortic sinus just below the sinotubular ridge. Typically 0-10 mm in length. Rarely no LM (separate origins).
Left main Coronary Artery
Left Coronary Artery
Left Anterior Descending
• Coursedown the anterior interventriculargroove-usually reaches apex. In 22% of cases does not reach apex.
• Branchesseptals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus (courses like 1st diagonal).
• LADSupplies anterolateral, apex and septum; ~45%-55% of left ventricle.
Left Coronary Artery
Left Circumflex Coronary Artery
• Originfrom distal LMCA.
• Coursedown distal left AV groove.
• Branchesobtuse marginal, posterolaterals-supply posterolateral LV, anterolateral papillary muscle. SA node artery-38%.
• Supplies15%-25% of LV, unless dominant (supplies 40-50% of LV).
Left Coronary ArteryOptimal angiographic views
Left Coronary ArteryOptimal angiographic views
Naber et al, Eurointervention 2010
Left Coronary ArteryOptimal angiographic views
Naber et al, Eurointervention 2010
Left Coronary ArteryOptimal angiographic views
Naber et al, Eurointervention 2010
Left Coronary ArteryOptimal angiographic views
RAO 30, CRANIAL 30RAO 20, CAUDAL 20
Left Coronary ArteryOptimal angiographic views
LAO 50, CAUDAL 45 LAO 30, CRANIAL 30
Venous bypass grafts and internal mammary artery
Venous bypass grafts and internal mammary artery
Rentrop ClassificationGrades of collateral filling from the contralateral vessel
Rentrop et al, J Am Coll Cardiol. 1985 Mar;5(3):587-92.
0 : none1 : filling of side branches of the artery to be dilated via collateral
channels without visualization of the epicardial segment 2 : partial filling of the epicardial segment via collateral channels; 3 : complete filling of the epicardial segment of the artery
being dilated via collateral channels.
Werner ClassificationAngiographic assessment by Doppler flow and pressure recordings
Werner et al, Circulation. 2003 Apr 22;107(15):1972-7
CC grade 0: no continuous connection (A: LAD to PDA-arrow, interrupted-arrowheads)CC grade 1: threadlike continuous connection (E: RCA RVB to LAD-arrowhead)CC grade 2: side branch–like connection (F: LCX and RCA marginal branch, arrows)
Coronary Chronic Total Occlusion (CTO) retrograde filling of the Right Coronary Artery (RCA) via(A) septal collaterals (B) epicardial collaterals (C) saphenous vein graft with subocclusive lesion of the distal anastomosis
(D) occluded distal Left Anterior Descending artery (LAD) is filled via a septal loop
Classification of Collateral Connections
Common collateral pathways observed with RCA occlusion
Common collateral pathways observed with LCX occlusion
Common collateral pathways observed with LAD occlusion
Left ventriculogramAnalysis of global and regional left ventricle function
Naber et al, Eurointervention 2010
Left ventriculogramAnalysis of global and regional left ventricle function
Coronary dominance
• The coronary artery responsible for perfusing the inferior septum is referred to as the PDA and is known as the dominant artery
• In 90% of patients the RCA is the dominant artery on the basis of this anatomical definition.
• When both the RCA and the LCA provide a posterior descending branch, the system is said to be “balanced”.
Coronary anatomic variations are complementary
• A short LAD (type I) is usually compensated for by a longer PDA running over the apex.
• A longer LAD (type III) running over the apex will be associated with a rather short PDA
• In all other cases the LAD is considered to be type II. • In the case of a right dominant coronary anatomy the importance and number of the
posterolateral branches of the RCA will vary inversely with the importance and number of the lateral branches from the LCX.
Anomalous Coronary Circulation
Paolo Angelini Circulation. 2007;115:1296-1305
Classification of Coronary Anomalies in Human Hearts
Anomalous Coronary Circulation
Paolo Angelini Circulation. 2007;115:1296-1305
Incidence of Coronary Anomalies and Patterns, asObserved in a Continuous Series of 1950 Angiograms
• Anatomical variants of the classical
blueprint should be acknowledged
especially since some coronary
anomalies may cause sudden death
in young athletes in the absence of
additional heart abnormalities.
• CT angiography and/or cardiac MRI
are excellent tools for identifying
coronary artery anomalies and
defining their course and relationship
to the great vessels and surrounding
structures
Anomalous Coronary Circulation
Paolo Angelini Circulation. 2007;115:1296-1305
a. Single coronary artery eitheroriginating from the left aortic sinus orfrom the right aortic sinus
Anomalous Coronary Circulation
Paolo Angelini Circulation. 2007;115:1296-1305
a. Single coronary artery either originating from the left aortic sinus or from theright aortic sinus
Anomalous Coronary Circulation
Paolo Angelini Circulation. 2007;115:1296-1305
b. Anomalous origin of the left main coronary artery originating from the right aortic sinus. Four different trajectories of the left main coronary artery are known: 1. anterior of the pulmonary artery, 2. posterior of the pulmonary artery, 3. inter-arterial between the aorta and the pulmonary trunk*4. an intraseptal course.
Anomalous Coronary Circulation
*The trajectory between the aorta and the right ventricular outflow tract (RVOT)has been associated with different coronary syndromes due to compression of the left main stem in case of dilatation of either the aorta or RVOT
c. Anomalous origin of the left circumflex coronary artery from the right aortic sinus or directly from the proximal RCA. This anomaly can already be suspected from the ventriculogram (obtained in RAO) showing the contour of the anomalous circumflex artery passing behind the right coronary sinus; this is known as the “aortic root sign or Page’s sign”
Anomalous Coronary Circulation
d. Anomalous origin of the right coronary artery from the left aortic sinus
Anomalous Coronary Circulation
e. Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA or Bland-White-Garland syndrome). It is usually the cause of severe myocardial ischemia and infarction during the first months after birth. Only 25% of patients will reach adult age
Anomalous Coronary Circulation
Coronary fistulas are frequent and may vary from very small, multiple to very extensive fistulas.Fistulas can cause significant under-perfusion. Approximately 50% of the fistulas arise from the RCA, and 50% from the LCA. In 50% of cases the fistula drains into the right ventricle, 25% into the right atrium, followed by the pulmonary artery, left atrium and finally the left ventricle.
Coronary Fistulas
Myocardial Bridges
Myocardial bridges are not infrequently seen in asymptomatic patients and occur when a segment of an epicardial coronary artery tunnels through the myocardium. The typical location is the mid segment of the LAD, although other locations have been reported, such as diagonal and marginal branches, the PDA and even the left main.
Myocardial Bridges
On angiography one sees typically a systolic compression with diameter reduction which varies from mild (less than 50% diameter reduction) to severe (more than 75% diameter reduction)
Myocardial Bridges
Data analysis, diagnosis
Left ventriculogramAnalysis of global and regional left ventricle function
Left ventriculogramQualitative description of regional function abnormalities
Left ventriculogramAnalysis of global and regional left ventricle function
Tako-Tsubo pattern in the absence of significant coronary lesions
Left ventriculogramAnalysis of global and regional left ventricle function
Josef Stehlik et al. Circulation. 2004;109:e203-e204
Left ventriculogram in RAO position showing basal inferior aneurysm with laminated thrombus
Left ventriculogramAssessment of mitral insufficiency from left ventriculography
LV dimensions, filling pressures, left atrial dimensions, presence of atrial fibrillation, the acute versus chronic regurgitation, rate and injected volume affect the degree of regurgitation.
Analysis of the coronary angiogramDegree of stenosis
Routinely estimated by online visual screening by the operator (at least two unforshortened orthogonal views)• normal (<25%)• low grade stenoses (25-49%)• intermediate grade stenoses (50-74%)• high grade stenoses (75-90%)• subtotal (91-99%) • total occlusion (100%)
Misclassification can occur due to• coronary spasm• misdiagnosed coronary anomalies• deep intubation of ostial stenoses• poststenotic dilatation• inadequate judgement by the operator
Analysis of the coronary angiogramDegree of stenosis, alternative methods
Quantitative coronary angiography (QCA) is an automated, computer based method for the analysis of two dimensional coronary angiographic images with automated contour detection.
Analysis of the coronary angiogramDegree of stenosis, alternative methods
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are intracoronary imaging methods which can be used in addition to the two-dimensional angiography and allow for true three-dimensional quantification of coronary dimensions
Analysis of the coronary angiogramDegree of stenosis, alternative methods
Analysis of the coronary angiogramMorphology of coronary stenosis
AHA/ACC classification system
Analysis of the coronary angiogramMyocardial perfusion
Thrombolysis in myocardial infarction (TIMI) flow grading has been used to assess, in a qualitative fashion, the degree of restored perfusion achieved after thrombolysis or angioplasty in patients with acute myocardial infarctionThe TIMI frame count was subsequently proposed as a semi-quantitative method to quantify myocardial perfusion.
Analysis of the coronary angiogramMyocardial perfusion
MBG score; washout of contrast from the microvasculature in the acute infarctionpatient is coupled to prognosis. Better blush scores indicate better myocardialsalvage
Analysis of the coronary angiogramScoring systems
AHA/ACC classification system
Analysis of the coronary angiogramScoring systems, Leaman score
Leaman et al, Circulation, 1981;63:285-99
Based on the severity of lumen diameter narrowing (a lesion is defined as significant when 50% diameter reduction is present by visual assessment) and weighed according to the usual blood flow to the myocardium in each vessel or vessel segment
Analysis of the coronary angiogramScoring systems, Classification of bifurcations
An anatomical-based description of the three components of a bifurcation lesion. Before the first comma, 1 or 0 depending on the presence or not of > 50% stenosis in the proximal main vessel, between the two commas the same for distal main vessel, after the second comma the same for side branch
Medina et al, Rev Esp Cardiol. 2006;59:183.
Analysis of the coronary angiogramScoring systems, SYNTAX score
Coronary anatomy classification with respect to the number of lesions and their functional impact, location and complexity. This scoring system combines the elements from the AHA system, the Leaman score and the ACC/AHA lesion classification system as well as elements from the bifurcation and trifurcation lesion classification, and the CTO classification system
Sianos et al, EuroIntervention. 2005;1:219-27.
Complications
Death
Stroke
Access site complications (2-5% incidence on femoral approach)
Reactions to contrast medium
Hypotension (vasovagal, drug induced, Cardiac tamponade, Retroperitoneal bleeding,
anaphylactic Shock
Cardiac arrhythmias
Pulmonary oedema
Myocardial ischemia
Vascular dissections (dissection of the access vessel and of the aorta, dissection of a
coronary artery or of the ascending aorta)
Needlestick injuries
Mistakes, pitfalls during interpretation
Poor and inhomogeneous filling of the coronary vessels due to inadequate force of manual injection.
Standard routine protocol (fixed number of injections and projection) should be overruled each time there is doubt regarding some segments due to superimposition, foreshortening, angulation or looping of vessels.
Catheter spasm is often seen after intubation of the RCA and more rarely with intubation of the left main stem.
Coronary spasm (provocation tests with ergonovine, acetylcholine available)
Anomalous origin of the left circumflex coronary artery from the right sinus of Valsalvaor from the RCA may occasional be missed
Total amputation of a coronary branch typically in case of occlusion of the mid LAD in the absence of collateral may occasionally be missed
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