Coronary Anatomy, Variants and Lesion Characteristics

Coronary Anatomy, Variants and Lesion

Characteristics

Coronary Anatomy, Variants and Lesion

CharacteristicsGeorge W. Vetrovec, M.D.

Medical College of Virginia CampusVirginia Commonwealth University

January 2003

George W. Vetrovec, M.D.Medical College of Virginia CampusVirginia Commonwealth University

January 2003

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TERMS OF USETERMS OF USE

Coronary Angiography

Optimal Coronary Angiography

Optimal Coronary AngiographyGoal is to adequately opacify coronary artery without

streamingGoal is to adequately opacify coronary artery without streaming

• Properly positioned catheterProperly positioned catheter• Sufficiently large catheter lumen for necessary Sufficiently large catheter lumen for necessary

and available contrast injectionand available contrast injection• Always insure “reflux”Always insure “reflux”


Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

Routine Angiographic ViewsRoutine Angiographic Views

Left Coronary• Shallow RAO, AP Caudal• LAO Caudal• LAO Cranial• RAO Cranial

Right Coronary• LAO Cranial• AP Cranial, Shallow RAO• LAO Caudal

Left Coronary• Shallow RAO, AP Caudal• LAO Caudal• LAO Cranial• RAO Cranial

Right Coronary• LAO Cranial• AP Cranial, Shallow RAO• LAO Caudal

Optimal Coronary Angiographic Views: Left Main

Optimal Coronary Angiographic Views: Left Main

Segment Routine AdjunctiveOstial LAO Caudal AP Caudal

Body RAO Caudal AP Caudal RAO Cranial

Distal LAO Caudal LAO CranialRAO Caudal


Body RAO Caudal AP Caudal RAO Cranial

Distal LAO Caudal LAO CranialRAO Caudal

Left Main: LAO Caudal Left Main: LAO Caudal

Optimal Coronary Angiographic Views: Left Anterior DescendingOptimal Coronary Angiographic Views: Left Anterior Descending

Segment Routine AdjunctiveOstial LAO Caudal AP/RAO Caudal

Body RAO Caudal AP Cranial LAO&RAO Cranial

Distal RAO LAO CranialRAO Caudal

Segment Routine AdjunctiveOstial LAO Caudal AP/RAO Caudal

Body RAO Caudal AP Cranial LAO&RAO Cranial

Distal RAO LAO CranialRAO Caudal

LAD: RAO CranialLAD: RAO Cranial

LAD–Diag Lesions in the AP Cranial View

LAD–Diag Lesions in the AP Cranial View

AP Cranial: Distal Stent DissectionAP Cranial: Distal Stent Dissection

Optimal Coronary Angiographic Views: Circumflex

Optimal Coronary Angiographic Views: Circumflex


Body Shallow RAO AP Caudal LAO LAO cranial

Distal Shallow LAO LAO CranialShallow RAO AP caudal


Body Shallow RAO AP Caudal LAO LAO cranial

Distal Shallow LAO LAO CranialShallow RAO AP caudal

Proximal Ramus StenosisProximal Ramus Stenosis

Optimal Coronary Angiographic Views: Right Coronary Artery

Optimal Coronary Angiographic Views: Right Coronary Artery

Segment Routine AdjunctiveOstial/Prox LAO Cranial Lateral(90-110)

AP Caudal

Mid Vessel Shallow RAO LateralLAO Caudal

Distal Bifurcation LAO Cranial AP Cranial

PDA Shallow RAO AP Cranial

PLB AP caudalLateral Cranial

Segment Routine AdjunctiveOstial/Prox LAO Cranial Lateral(90-110)

AP Caudal

Mid Vessel Shallow RAO LateralLAO Caudal

Distal Bifurcation LAO Cranial AP Cranial

PDA Shallow RAO AP Cranial

PLB AP caudalLateral Cranial

Optimal Coronary Angiographic Views: Vein Bypass Grafts

Optimal Coronary Angiographic Views: Vein Bypass Grafts

Segment Routine AdjunctiveOstial LAD Shallow RAO AP Caudal

RCA LAO LAO Caudal

Body RAO LAO

Segment Routine AdjunctiveOstial LAD Shallow RAO AP Caudal

RCA LAO LAO Caudal

Body RAO LAO

Optimal Coronary Angiographic Views: Bypass Graft Insertion Site

Optimal Coronary Angiographic Views: Bypass Graft Insertion Site

SEGMENT ROUTINE* ADJUNCTIVELAD/Diag AP Cranial Lateral

Circ LAO AP Caudal RAO Cranial

RCA LAO Caudal LateralRAO Caudal

PDA/PLB(Bif) AP Cranial Lateral

PDA/PLB (Mid) LAO Cranial RAO Caudal

SEGMENT ROUTINE* ADJUNCTIVELAD/Diag AP Cranial Lateral

Circ LAO AP Caudal RAO Cranial

RCA LAO Caudal LateralRAO Caudal

PDA/PLB(Bif) AP Cranial Lateral

PDA/PLB (Mid) LAO Cranial RAO Caudal

*Similar Views for same area of native vessel*Similar Views for same area of native vessel

Optimal Coronary Angiographic Views: Internal Mammary GraftOptimal Coronary Angiographic Views: Internal Mammary Graft

SEGMENT ROUTINE ADJUNCTIVEOstial Shallow RAO LAO Cranial

Mid Vessel Shallow RAO Lateral

Insertion to:LAD RAO Cranial Lateral (+/-)

RCA LAO LateralRAO

Left Subclavian AP RAO Cranial

SEGMENT ROUTINE ADJUNCTIVEOstial Shallow RAO LAO Cranial

Mid Vessel Shallow RAO Lateral

Insertion to:LAD RAO Cranial Lateral (+/-)

RCA LAO LateralRAO

Left Subclavian AP RAO Cranial


Lesion Classification: Coronary Angiographic Outcomes

Predictors Based on AHA/ACC Grading System

Lesion Classification: Coronary Angiographic Outcomes

Predictors Based on AHA/ACC Grading System

Type ADiscreteConcentricReadily accessibleSmooth ContourLittle or no calcification Non ostialNo major side branch involvedAbsence of thrombus

Type ADiscreteConcentricReadily accessibleSmooth ContourLittle or no calcification Non ostialNo major side branch involvedAbsence of thrombus


Lesion Classification: Coronary Lesion Classification: Coronary Angiographic Outcomes Predictors Based Angiographic Outcomes Predictors Based

on AHA/ACC Grading Systemon AHA/ACC Grading System

Type BType BTubularTubularEccentricEccentricModerate tortuosityModerate tortuosityModerately angulated (45 – 90Moderately angulated (45 – 9000))Irregular contourIrregular contourModerate – heavy calcificationModerate – heavy calcificationTotal occlusion (< 3 months)Total occlusion (< 3 months)Ostial Ostial Bifurcation lesion Bifurcation lesion Thrombus presentThrombus present

Note: BNote: B11 = characteristic only; B = characteristic only; B22 = 2 or more characteristics = 2 or more characteristics


Lesion Classification: Coronary Lesion Classification: Coronary Angiographic Outcomes Predictors Based Angiographic Outcomes Predictors Based

on AHA/ACC Grading Systemon AHA/ACC Grading System

Type CType C DiffuseDiffuse

Excessive TortuosityExcessive TortuosityExtremely angulated Extremely angulated Total occlusion (> 3 months)Total occlusion (> 3 months)Inability to protect major side branchInability to protect major side branchDegenerated vein graftDegenerated vein graft


Distal Blood Flow/Collateral Distal Blood Flow/Collateral Classification Based on TIMI TrialClassification Based on TIMI Trial

TIMI GradeTIMI Grade Contrast FlowContrast Flow

00 (No perfusion)(No perfusion) Antegrade flow to lesion; Antegrade flow to lesion; no flow beyond occlusionno flow beyond occlusion

11 (Penetration with(Penetration with Contrast passes beyond Contrast passes beyond minimal perfusion)minimal perfusion) lesion but does not opacify lesion but does not opacify

distal vessel during cine rundistal vessel during cine run

22 (Partial perfusion) (Partial perfusion) Contrast passes obstruction Contrast passes obstruction and fills distal vessel.However, and fills distal vessel.However,

rate rate of filling and/or washout slower of filling and/or washout slower than than vessel segments outside lesionvessel segments outside lesion

33 (Complete perfusion)(Complete perfusion) Contrast passes freely into distal Contrast passes freely into distal at at same visual rate as unaffected same visual rate as unaffected

adjacent vesselsadjacent vessels


Distal Blood Flow/Collateral Classification Based on TIMI

Trial

Distal Blood Flow/Collateral Classification Based on TIMI

TrialCollateral Supply Contrast Flow

1 Absent2 Minimal3 Well developed

Collateral Supply Contrast Flow1 Absent2 Minimal3 Well developed

Adapted from TIMI


NHLBI Classification System for Coronary Dissection

NHLBI Classification System for Coronary Dissection

DissectionA Small radiolucent area within the lumen of the vesselB Linear, nonpersisting extravasation of contrastC Extraluminal, persisting extravasation of contrastD Spiral-shaped filling defectE Persistent lumen defect with delayed anterograde flowF Filling defect accompanied by total coronary occlusion

Length (in mm)Measure end to end for type B through F dissections

StainingPersistence of contrast within the dissection after

washout of contrast from the remaining portion of the vessel

DissectionA Small radiolucent area within the lumen of the vesselB Linear, nonpersisting extravasation of contrastC Extraluminal, persisting extravasation of contrastD Spiral-shaped filling defectE Persistent lumen defect with delayed anterograde flowF Filling defect accompanied by total coronary occlusion

Length (in mm)Measure end to end for type B through F dissections

StainingPersistence of contrast within the dissection after

washout of contrast from the remaining portion of the vessel


Coronary AnomaliesCoronary Anomalies

• Common: Insignificant– Conus Separate Ostium from RCA 50%– Left Circ from RCA 0.3%

• Uncommon: Clinically Significant– LM from Proximal RCA– Courses between Great Vessels– Associated with sudden Death

• Common: Insignificant– Conus Separate Ostium from RCA 50%– Left Circ from RCA 0.3%

• Uncommon: Clinically Significant– LM from Proximal RCA– Courses between Great Vessels– Associated with sudden Death


Left Circumflex from RCALeft Circumflex from RCA


Left Main Arising from RCALeft Main Arising from RCA


Left Main from RCALeft Main from RCA

Angulationat

originof LM

Compression

of LM


Adapted from Seroth et al. Am J Cardiol 1990;65:891-898

LM-Right Sinus of ValsalvaLM-Right Sinus of ValsalvaSeptal CourseSeptal Course



LM-Right Sinus of Valsalva LM-Right Sinus of Valsalva Retroaortic CourseRetroaortic Course



LM-Right Sinus of ValsalvaLM-Right Sinus of ValsalvaAnterior Free WallAnterior Free Wall


LM-Right Sinus of Valsalva Interarterial Course

LM-Right Sinus of Valsalva Interarterial Course


Anomalous LM: Interarterial Course

Anomalous LM: Interarterial Course

Coronary Anatomy, Variants and Lesion Characteristics

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