Identification of coronary arteries by different angiographic views - Dr. Atik

Welcome to

Morning Session

Welcome to

Morning Session

Dr. Mohammad Atikur RahmanStudent

MD Cardiology (Final Part)

Session: January-2014

Department of Cardiology

UCC, BSMMU.

Identification of Coronary Arteries

by Different Angiographic Views

Identification of Coronary Arteries

by Different Angiographic Views

Basic Coronary Artery Anatomy

Basic Coronary Artery Anatomy

Sternocostal Aspect

Diaphragmatic Aspect

Right Coronary ArteryRight Coronary Artery

OriginRight aortic sinus (lower origin than LCA)

CourseDown right AV groove toward crux of the heart, gives off PDA (85%) 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

Basic Anatomy


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.

Other Branches


Right Ventricular (Acute Marginal) Branches)Arise 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.

Other Branches


LAO (30) Cranial(30)particularly for distal bifurcation (AP Cranial may be better).

RAOmain shaft; cranial enhances distal vessels and very proximal; caudal may help with Shepherd’s crook.

Lateralbifurcations with RV branches-distal bifurcation, particularly with cranial.

Optimal View(s)

Left Coronary ArteryLeft Coronary Artery

Originupper portion of left aortic sinus just below the sinotubular ridge. Typically 0-10 mm in length. Rarely no LM (separate origins).

Optimal ViewsLAO caudal and cranial; AP-caudal, cranial or flat.

Left Main Coronary Artery

Left Anterior Descending ArteryLeft Anterior Descending Artery

Coursedown the anterior interventricular groove-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 Circumflex ArteryLeft Circumflex 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 ArteryLeft Coronary Artery

AP (30)CaudalLMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO may be useful.

AP (40)CranialLMCA, LAD, diagonals, septals, distal Cx-may need RAO to separate LAD and Cx.

(45)LAO (35) CranialLMCA, LAD, diagonals, septals, and distal Cx.

(45)LAO (30) CaudalLMCA, Cx,and prox LAD.

Laterals (cranial, caudal)may be helpful.

Optimal Views

Standard Angiographic ViewsStandard Angiographic Views LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal

Best for visualizing left main, proximal LAD and proximal LCx

RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal

Best for visualizing left main bifurcation, proximal LAD and the proximal to mid LCx

Shallow RAO-Cranial view: 00 to 100 RAO and 250 to 400 cranial

Best for visualizing mid and distal LAD and the distal LCx (LPDA and LPL)

Separates out the septals from the diagonals

LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial

Best for visualizing mid and distal LAD, and the distal LCx in a left dominant system

Separates out the septals from the diagonals

Left Coronary Artery

Standard Angiographic ViewsStandard Angiographic Views PA projection: 00 lateral and 00 cranio-caudal

Best for visualizing ostium of the left main

PA-Caudal view: 00 lateral and 200 to 300 caudal

Best for visualizing distal left main bifurcation as well as the proximal LAD and the proximal to mid LCx

PA-Cranial view: 00 lateral and 300 cranial

Best for visualizing proximal and mid LAD

Left lateral view:

Best for visualizing proximal LCx, proximal and distal LAD

Also good for visualizing LIMA to LAD anastomotic site

Left Coronary Artery (other views)

Standard Angiographic ViewsStandard Angiographic Views

LAO 30: 300 LAO

Best for visualizing ostial and proximal RCA

RAO 30: 300 RAO

Best for visualizing mid RCA and PDA

PA Cranial: PA and 300 cranial

Best for visualizing distal RCA bifurcation and the PDA

Right Coronary Artery

Standard Angiographic ViewsStandard Angiographic Views An easy way to identify the tomographic views is to use the anatomic

landmarks - catheter in the descending aorta, spine and the diaphragm. The rough rules are:

RAO vs. LAO- If the spine and the catheter are to the right of the image, it is LAO and vice versa. If central, it is likely a PA view

Cranial vs. caudal - If diaphragm shadow can be seen on the image, it is likely cranial view, if not, it is caudal

Catheter and spine to the LEFT

RAO view

No diaphragm shadow

Caudal view

Catheter at the CENTER

PA view

No diaphragm shadow

Caudal view

Spine to the

RIGHTLAO view

Diaphragm shadow

Cranial view

Standard Angiographic ViewsStandard Angiographic ViewsLeft Coronary Artery

RAO 20 Caudal 20

LMLAD

Diagonal

SeptalsDistal LAD

LCx

RAO 20 Caudal 20Knowledge of the orientation of the artery

for a given view can help identify the probable path of the artery in the setting of

complete occlusion

Distal LAD fills by collaterals

LAD

Best for visualization of LM bifurcation and

proximal LAD and LCx


LAO 50 Cranial 30

LM

LAD

DiagonalSeptals

Distal LAD

LCx

PA 0 Cranial 30

LM

LAD

Diagonal

Septals

Distal LAD

LCx

Best for visualization of LM proximal and mid LAD

Best for visualization of proximal and mid LAD and splaying of the septals

from the diagonals. Also ideal for visualization of distal LCx


PA0 Caudal 30

LM

LADDiagonal

Septals

Distal LAD

LCx

LAO 50 Caudal 30

OM

LM

LADDiagonal

Distal LAD

LCx

OM

‘Spider’ view

Best for visualization of LM bifurcation and proximal

LAD and LCx

Best for visualization of LM bifurcation, proximal LAD and LCx

and OM

Standard Angiographic ViewsStandard Angiographic ViewsRight Coronary Artery

LAO 30

Proximal RCA

PDADistal RCA

Mid RCA

RAO 30

Mid RCA

PDA/PLV

PA 0 Cranial 30

Proximal RCA

PDADistal RCA

Mid RCA

Best for visualization of ostial and proximal RCA

Best for visualization of mid RCA and PDA

Best for visualization of distal RCA and its bifurcation

A-P PROJECTIONA-P PROJECTION

RIGHT ANTERIOR OBLIQUE PROJECTION AT 30° (RAO 30°)

RIGHT ANTERIOR OBLIQUE PROJECTION AT 30° (RAO 30°)

LEFT ANTERIOR OBLIQUE PROJECTION AT 55/60° (L.A.O. 55/60°)

LEFT ANTERIOR OBLIQUE PROJECTION AT 55/60° (L.A.O. 55/60°)

LEFT ANTERIOR OBLIQUE PROJECTION AT 55/60°COMBINED WITH A CRANIAL

ANGULATION OF 20°

LEFT ANTERIOR OBLIQUE PROJECTION AT 55/60°COMBINED WITH A CRANIAL

ANGULATION OF 20°

LEFT LATERAL PROJECTIONLEFT LATERAL PROJECTION

LEFT ANTERIOR OBLIQUE PROJECTION AT 45°COMBINED WITH A CAUDAL

ANGULATION OF 15°

LEFT ANTERIOR OBLIQUE PROJECTION AT 45°COMBINED WITH A CAUDAL

ANGULATION OF 15°

RIGHT ANTERIOR OBLIQUE PROJECTION AT 45°

RIGHT ANTERIOR OBLIQUE PROJECTION AT 45°

RIGHT ANTERIOR OBLIQUE PROJECTION AT 120°COMBINED WITH A CRANIAL

ANGULATION OF 10°

RIGHT ANTERIOR OBLIQUE PROJECTION AT 120°COMBINED WITH A CRANIAL

ANGULATION OF 10°

LEFT LATERAL PROJECTIONLEFT LATERAL PROJECTION

THANK YOU ALL THANK YOU ALL

Health & Medicine

Identification of coronary arteries by different angiographic views - Dr. Atik