Angulated views in coronary angiography,an introductory lecture for cath lab technicians dr awadhesh

1. Angulated views in coronary
angiography
An Indroductory lecture for cath lab technicians
Dr Awadhesh Kumar Sharma
MD(Gold Medalist),DM Cardiology

2. Dr Awadhesh Kumar Sharma
 Dr.Awadhesh Kumar Sharma is a young, diligent and dynamic interventional cardiologist. He did
his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB
Medical college Jhansi.Then he did his superspecilization degree DM in Cardiology from PGIMER
& DR Ram Manohar Lohia Hospital New Delhi. He had excellent academic record with Gold
medal in MBBS,MD and first class in DM. He was also awarded chief ministers medal in 2009 for
his academic excellence by former chief minister of UP Hon. Mayawati in 2009.He is also receiver
of GEMS international award. He had many national & international publications. He had special
interest in both invasive & non invasive cardiology. He had performed more then 5000 invasive
cardiac intervention procedures successfully till date including coronary angiography, simple &
complex angioplasty, peripheral vessels angiography & angioplasty, carotid angiography &
angioplasty,ASD ,PDA device closures, Mitral & pulmonary valvotomy. He is also in editorial board
of many national & international journal- Journal of clinical medicine & research(JCMR),Clinical
cardiology update, EC Pulmonology and Respiratory Medicine. He is also active member of
reviewer board of many journals. He is also international associate fellow of American college of
cardiology. He is active member of many professional bodies including Indian MedicalAssociation,
Cardiological Society of India,APVIC, ICC,API. He had worked in NABHApproved Gracian
Superspeciality Hospital Mohali as Consultant Cardiologist since 2014-2016. Currently he is
working asAssistant Professor of cardiology at LPS Institute of Cardiology, GSVM Medical college,
Kanpur(UP)under Govt of UP.

3. Cineangiographic equipments
 A Generator
 X Ray tube – under the patients table
 Image Intensifier- attached to a positioner such as
C-arm, over the patients table
 Optical system
 Digital convertor
 TV monitors
 Control Unit

5. CranialView- image intensifier is tilted towards the
head of the patient
CaudalView- image intensifier is tilted down
toward the feet of the patient
APView – image intensifier is in central position
LateralView – image intensifier is on left side of the
patient horizontally at body level

6. Importance of angulated
views
 Proper delineation of coronary & peripheral
vascular anatomy
 Origin & course of vessel
 Eccentric lesion

7. Standard 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

8. Standard Angiographic Views
RAO-Caudal view: 100
to 200
RAO and 150
to 200
caudal
 Best for visualizing-
 Left main bifurcation
 Proximal LAD
 Proximal to mid LCx
Left Coronary Artery

9. Standard Angiographic Views
Left Coronary Artery
RAO 20 Caudal 20
LM
LAD
Diagonal
Septals
Distal
LAD
LCx
RAO 20 Caudal 20
Knowledge 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

10.  LAO-Cranial view: 300
to 600
LAO and 150
to 300
cranial
Best for visualizing
 Mid and distal LAD
 Distal LCx in a left dominant system
 Separates out the septals from the diagonals
Left Coronary Artery

11. Standard Angiographic Views
Left Coronary Artery
LAO 50 Cranial 30
LM
LAD
Diagonal
Septals
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

12. Left Coronary Artery
 PA-Cranial view: 00
lateral and 300
cranial
 Best for visualizing -
 Mid LAD
 Distal LAD

13. Left Coronary Artery
 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

14. Left Coronary Artery
LAO-Caudal view: 400
to 600
LAO and 100
to 300
caudal
Best for visualizing-
 Left main,
 Proximal LAD
 Proximal LCx
 Spider view

15. Standard Angiographic Views
Left Coronary Artery
PA0 Caudal 30
LM
LAD
Diagonal
Septals
Distal
LAD
LCx
LAO 50 Caudal 30
OM
LM
LAD
Diagonal
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

16. Left Coronary Artery
PA-Caudal view: 00
lateral and 200
to 300
caudal
Best for visualizing
 Distal left main bifurcation
 Proximal LAD
 Proximal to mid LCx

17. Left Coronary Artery
PA projection: 00
lateral and 00
cranio-caudal
Best for visualizing
 Ostium of the left main

18. Left lateral view:
Best for visualizing
Proximal LCx,
Proximal and distal LAD
Also good for visualizing LIMA to LAD anastomotic site
Left Coronary Artery

19. Standard 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
 Left lateral view: Left Lateral 900
 Ostium of the RCA
 Midportion of the RCA
 Separation of RCA with its RV branches
Right Coronary Artery

20. Standard Angiographic Views
Right Coronary Artery
LAO 30
Proximal
RCA
PDA
Distal
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

21. RAO and LAO
Ventriculography:
RAOVentricle  LAOVentricle

22. Left Ventriculogram
Systolic View
RAO

23. Left Ventriculogram
Diastolic View
RAO

24. Cerebral circulation
APView- Common carotid,External carotid,
Internal carotid,Vertebral arteries
LateralView- Bifurcation of Common carotid
artery into External carotid & Internal carotid
artery

25. Commonly used angiographic
views
 Most favorable angulation for iliac angiography is the
contralateral oblique angle, generally 30 to 40 °
 The optimal view for the common femoral bifurcation is 30
to 45° of ipsilateral oblique angulation
 SFA can be imaged in an anteroposterior view with the
addition of an oblique angle if a stenosis is suspected.
 The popliteal artery, tibeoperoneal trunk, and trifurcation
are best imaged in an ipsilateral oblique angle (30°).
 Infrapopliteal runoff can be performed in either an
anteroposterior or an ipsilateral oblique projection
N Engl J Med. 2006;354:379 –386
Vasc Endovascular Surg. 2002;36:439–445
LAO 30