Identification of coronary arteries by different angiographic views - Dr. Atik
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Transcript of 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
Right Coronary ArteryRight Coronary Artery
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 Coronary ArteryRight Coronary Artery
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
Right Coronary ArteryRight Coronary Artery
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
Standard Angiographic ViewsStandard Angiographic ViewsLeft Coronary Artery
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
Standard Angiographic ViewsStandard Angiographic ViewsLeft Coronary Artery
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