Coronary Angiography: A Continuing Education Program

Coronary Angiography:
A Continuing Education Program

Objectives
• At the end of this presentation you will be able to:

– Locate the coronary arteries and their associated branches on an
anatomical drawing of the heart
– Identify the coronary arteries in different angiographic projections
– Describe the concepts of collateral circulation
– Define the concept of coronary artery dominance
– State the purpose of ventriculography
Coronary Angiographic Views Company Confidential 2

SE2924424 Rev. D © 2010 Abbott
Coronary Anatomy and Circulation
Circulation Diagram
• Right Heart – collects de-oxygenated blood
from the body and sends to lungs
• Left Heart – collects oxygenated blood from
the lungs and sends to body
Ascending Aorta
Right
Graphic source: anatimation.com/images/heart_diagram.jpg
Coronary Left
Artery Coronary
Artery • Coronary blood supply is provided
by the coronary arteries
• If the coronary arteries become

occluded a heart attack can occur
Graphic source: http://www.familydoctor.co.uk/htdocs/CORONARY/CORON_specimen.html

Coronary Arteries
Aorta
Right
Coronary
Artery Left
Coronary
Artery
– Arise from the

ascending aorta
– Empty into the coronary
sinus
Graphic source: http://www.familydoctor.co.uk/htdocs/CORONARY/CORON_specimen.html

Coronary Artery Perfusion
• Coronary Arteries fill during Diastole (relaxation phase of the heart)

• During Systole (contraction phase) coronary arteries are constricted
Graphic source: www.cardiologysite.com

Anatomy Definitions
ANTERIOR FACING SURFACE MEDIAL MIDLINE SURFACE
SUPERIOR UPPER SURFACE LATERAL SIDE SURFACE
POSTERIOR REAR SURFACE CLOSE TO POINT

PROXIMAL OF REFERENCE
INFERIOR LOWER SURFACE DISTAL AWAY FROM POINT
OF REFERENCE
BASE
SUPERIOR POSTERIOR SURFACE
APEX
http://health.allrefer.com/health/atrial-fibrillation-flutter-heart-front-view.html

Coronary Artery Anatomy

Coronary Artery Branches
Right Coronary Artery Left Coronary Artery

• Acute Marginals • Left Main (LM)
• Posterior Descending • Left Anterior Descending (LAD)
Artery (PDA) – Diagonals
– Septals
• Posterior Lateral (PL)
• Left Circumflex (LCX)
– Obtuse Marginals (OM)

Right Coronary Artery
• Supplies blood
to the right
side of the
heart
– Right atrium Right
– Right ventricle Coronary
– Posterior and Artery
inferior walls
of the left
ventricle (if
dominant
system)

Left Main (LM)
Left Main
artery

Left Anterior Descending (LAD)
• Supplies blood to the
left ventricle:
– Anterior wall
– Lateral Wall
Left Main
– Apical Wall
– Ventricular septum
Left Anterior
Descending

Left Circumflex (LCX)
• Supplies blood
to the left
ventricle:
Left Main – Left atrium

– Lateral wall
Left – Posterior wall
Circumflex
– Inferior wall (if
dominant
LAD system)

Ramus Artery (Ramus Intermedius)
Left Main
Left
Circumflex
Ramus
LAD

Myocardial Infarction
Blocked Blood Supply
Occluded
Coronary
Artery
Damaged
Heart Muscle
Myocardial Infarction – Location determined by ECG
Source: Acute Coronary Care, M. Boldt,

Infarct Location
Infarct Coronary
EKG
Location Anatomy
Anterior Infarct V3 & V4 LAD
Lateral Infarct I, aVL, aVF, V5, V6 LCX
Inferior Infarct II, III, aVF RCA
Septal V1, V2 LAD
V1, V2 right Posterior

Posterior Infarct
sided EKG branch of RCA
Source: Acute Coronary Care, M. Boldt,

Angiographic Views

Procedure Room
1. Image 4. Image 5. Hemodynamic
Intensifier Monitor Monitor
3. C-arm
7. Crash
Cart
6. Power
Injector
2. X-ray
Tube
Coronary Angiography

Camera Angles
AP
LAO RAO
Source: www.cardiologysite.com

Camera Angles
Cranial
Source: www.cardiologysite.com Caudal

Angiographic Landmarks
• Spine
– LAO view - spine on right side of screen
– RAO view - spine on left side of screen
• Ribs – upward slope of the ribs will point to the catheter and to
the spine
• Sternum – sternal wires
• Catheter – lies against the spine

Angiographic Landmarks
Sternum
Catheter
Spine
Ribs


Identifying the Right Coronary Artery
LAO View
• Resembles the letter “C”
• PDA is generally seen more inferior
on the screen than the PL
• LAO view best separates the PDA
and PL branches

Spine
LAO view – RCA resembles the letter “C”

PDA more inferior
LAO/Cranial view - best separates the

PDA and PL branches
Identifying the Right Coronary Artery
RAO View
• Resembles the letter “L”

• PDA and PL can appear as
overlapped

Spine
RAO view – RCA resembles the letter

“L” (PDA & PL may appear overlapped)

Knowledge Check: Which artery? Which view?



Angiography: Right Coronary Artery




Left Coronary Artery

Identifying the Left Coronary Artery Branches
• RAO view – LAD will be “on top”
• LAO view – LAD will be “on left” (LLL)
• Both views - LCX lies closest to the spine
• Lateral view – LCX and LAD appear to

outline the heart

Angiography: Left Coronary Arteries
Left Coronary Artery Branches – RAO view
SPINE LAD
LCX
Catheter

Left Coronary Artery Branches – LAO view
Spine
LAD
LCX

Angiography: Left Coronary Arteries
Left Coronary Artery Branches – Lateral View
Catheter
Sternum
LAD
LCX

Knowledge Check: Left Coronary Artery Branches

Knowledge Check: Left Coronary Artery Branches

Angiography:
Knowledge Check: Left Left Coronary
Coronary ArteryArteries
Branches

BONUS Knowledge Check: Which view?
Where is the LAD? Where is the LCX?

Angiography: Left Coronary Artery Branches



Collateral Circulation

• Definition: Small capillary-like branches that form over time in

response to narrowed arteries; bypass vessels
• At times of increased exertion, collateral vessels may not deliver

enough blood.
It is thought that:
Collateral vessels are always
present in a dormant, microscopic
form, but chemicals released with
ischemia cause these vessels to
dilate.
There are 22 known collateral
pathways. Clevelandclinic.org

Described as:
Same side
• left-to-left
• right-to-right
Opposite side
• right-to-left
• left-to-right

Collateral Circulation: LAD Obstruction – 7 pathways

Collateral Circulation: LCX Obstruction – 5 pathways

Collateral Circulation: RCA Obstruction – 10 pathways

Angiography: Collateral Circulation

Coronary Artery Dominance

Dominance refers to the blood supply source to posterior and inferior wall of LV.
Determined by
which artery
gives rise to
the posterior
descending
(PDA) and
posterior
lateral (PL)
branches.
Source: www.cardiologysite.com

Angiography: Dominant Vessels
Right Dominant Left Dominant
Right – 85% Balanced – 7% Left – 8%

Knowledge Check: Identify the dominance for this
patient.
Tip: Which vessel is feeding the posterior and inferior wall of left ventricle?

Left Ventriculography

Ventriculography
• Purpose: to evaluate left ventricular
function
– Contractility
– Size
– Wall thickness
– Quality of valve function
• Measures the volume of blood ejected by
the left ventricle during a contraction
• Normal EF is approximately 50 - 70%
• Ejection Fraction (EF) is a good indicator of
survival after an MI

LV Gram - Systole

LV Gram - Diastole

Left Ventriculography

Coronary Artery Bypass Grafts

Coronary Artery Bypass Surgery
Common Terminology:
• CABG – Coronary Artery Bypass Graft
• Grafts sources
– LIMA – Left Internal Mammary Artery
– RIMA – Right Internal Mammary Artery
– SVG – Saphenous Vein Graft
– Radial – Radial Artery Graft
• Anastamosis – Graft to artery suture site
http://www.upstate.edu/cdb/grossanat/thoraxpath5.shtml

Coronary Artery Bypass Grafts
SVG - RCA LIMA - LAD

Angiography: Bypass Grafts
SVG to Right Coronary Artery Graft

Angiography: Bypass Grafts
Left Internal Mammary Artery (LIMA) to LAD Graft

Summary
• Can you state the main coronary arteries?

• Can you identify the associated branches for each main
coronary artery?
• Can you list the landmarks used to interpret the coronary
anatomy?
• How can you identify camera angulation?
• Can you define collateral circulation?
• How is coronary artery dominance determined?
• What is the purpose of a left ventriculogram?


Coronary Angiography: A Continuing Education Program

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Coronary Angiography: A Continuing Education Program

Enviado por

Direitos autorais:

Formatos disponíveis

Coronary Angiography:

A Continuing Education Program

• At the end of this presentation you will be able to:

– Identify the coronary arteries in different angiographic projections

– Describe the concepts of collateral circulation

– Define the concept of coronary artery dominance

– State the purpose of ventriculography

Coronary Angiographic Views Company Confidential 2

• If the coronary arteries become

Graphic source: http://www.familydoctor.co.uk/htdocs/CORONARY/CORON_specimen.html

Coronary Angiographic Views Company Confidential 3

– Arise from the

Graphic source: http://www.familydoctor.co.uk/htdocs/CORONARY/CORON_specimen.html

Coronary Angiographic Views Company Confidential 4

• Coronary Arteries fill during Diastole (relaxation phase of the heart)

Graphic source: www.cardiologysite.com

Coronary Angiographic Views Company Confidential 5

SUPERIOR UPPER SURFACE LATERAL SIDE SURFACE

POSTERIOR REAR SURFACE CLOSE TO POINT

Coronary Angiographic Views Company Confidential 6

Coronary Angiographic Views Company Confidential 7

Right Coronary Artery Left Coronary Artery

Coronary Angiographic Views Company Confidential 8

Coronary Angiographic Views Company Confidential 9

Coronary Angiographic Views Company Confidential 10

Coronary Angiographic Views Company Confidential 11

Left Main – Left atrium

Coronary Angiographic Views Company Confidential 12

Coronary Angiographic Views Company Confidential 13

Blocked Blood Supply

Source: Acute Coronary Care, M. Boldt,

Coronary Angiographic Views Company Confidential 15

Anterior Infarct V3 & V4 LAD

Lateral Infarct I, aVL, aVF, V5, V6 LCX

Inferior Infarct II, III, aVF RCA

Septal V1, V2 LAD

V1, V2 right Posterior

Source: Acute Coronary Care, M. Boldt,

Coronary Angiographic Views Company Confidential 16

Coronary Angiographic Views Company Confidential 17

Coronary Angiographic Views Company Confidential 19

Coronary Angiographic Views Company Confidential 20

Source: www.cardiologysite.com Caudal

Coronary Angiographic Views Company Confidential 22

Coronary Angiographic Views Company Confidential 23

Coronary Angiographic Views Company Confidential 24

Coronary Angiographic Views Company Confidential 25

LAO view – RCA resembles the letter “C”

Coronary Angiographic Views Company Confidential 26

PDA more inferior

LAO/Cranial view - best separates the

• Resembles the letter “L”

Coronary Angiographic Views Company Confidential 28

RAO view – RCA resembles the letter

Coronary Angiographic Views Company Confidential 29

Coronary Angiographic Views Company Confidential 30

Coronary Angiographic Views Company Confidential 31

Coronary Angiographic Views Company Confidential 32

Coronary Angiographic Views Company Confidential 33

Coronary Angiographic Views Company Confidential 34

Coronary Angiographic Views Company Confidential 35

Coronary Angiographic Views Company Confidential 36

Coronary Angiographic Views Company Confidential 37