Coronary angiography

1. Raja Lahiri

2. Introduction
 Angiography: Visualisation of the vascular bed via X-
ray/MRI with contrast injection
 Conventional
 CT
 MRA
 Conventional CAG: Current gold standard

3. History
1927
• Egas Moniz: Cerebral angiography
1929
• Werner Forssmann: Cardiac
catheterisation
1940
• Andre Cournand and Dickinson Richards:
Catheterisation and hemodynamics

4. History
 Initial attempts focussed on non
selective contrast injections in
aortic root
 Selective injections feared with
risk of ventricular fibrillation
based on animal studies
 Transient cardiac arrest with aortic
occlusion with balloon was used to
obtain better quality images
 1958: Accidental injection of
contrast in right coronary artery by
Dr. Mason Sones and his associateDr. F. Mason Sones

5. History
First Coronary Angiogram(RCA)
by Mason Sones
First aortocoronary saphenous vein
graft inserted by Rene Favaloro in May
1967

6. Indications
 Established CAD:
 To define coronary anatomy and formulate management
plan
 Emergent revascularisation in STEMI
 To confirm non invasive diagnosis of CAD
 Left ventricular dysfunction, ventricular arrhythmias,
ambiguous non invasive test results, out of hospital
cardiac arrest survivors
 Pre Surgical evaluation

7. Contraindications
 No absolute contraindication
 Anemia
 Renal dysfunction
 Active infection
 High bleeding risk
 Contrast Allergy

9. Cardiac catheterisation laboratory

10. Coronary angiography catheters

11. Contrast material
 High osmolality ionic contrast media:
 Not used nowadays
 High incidence of adverse events
 Low osmolar non ionic contrast agents:
 Most commonly used agent
 Well tolerated
 Iso osmolar non ionic contrast agents

13. Femoral
 Most frequently used access site
 Ease of access, lesser contrast and radiation exposure,
freedom to upgrade to bigger size sheaths
 Need for immobilisation, local site complications:
main drawbacks

14. Femoral

15. Access technique

16. Radial
 No need for immobilisation
 Lower rate of local vascular complications
 Increasingly being used as primary access site
 Slightly higher contrast and radiation exposure with
beginners
 Spasm, loops, failure to get access may require switch to
femoral route

17. Radial access tools

18. Radial access

19. Access sites (Other)
 Brachial
 Ulnar
 Radial in anatomical snuffbox

21. Angiography techniques
 Prior heparinisation
 Hemodynamic monitoring (Utmost important)
 Always check for pressure damping/ventricularisation
before injection
 Beware of air and clots

22. Contrast Injection
 Left coronary artery: 6-8ml over 2-3 seconds
 Right coronary artery: 4-6ml over 2-3 seconds
 Should be adequate to fill the coronary artery completely
without streaming
 Excessive contrast injection should be avoided
 Cine acquisition (@10fps) should continue till contrast
clears from the system

23. Angiographic projections

25. Angiographic views of the left coronary artery

26. Angiographic views of the right coronary artery

27. Angiographic projections

28. Left coronary artery angiogram

29. LMCA
 Best seen in a shallow LAO
projection with slight caudal
angulation
 Cranial angulation to
improve visualization of its
proximal and ostial segments.
 Steep LAO caudal (also called
the spider view) lays out the
terminal left main
bifurcation.
 Not helpful in the case of a
horizontally positioned heart,
in which situation a steep
RAO caudal view is
substituted.

30. LAD
 No single view adequately
depicts the entire course of
the LAD.
 The proximal LAD is best
visualized in steep LAO
projections with cranial
angulation, whereas the
middle and distal segments
are better seen in LAO and
RAO views with some caudal
angulation.
 The best view for most of the
diagonal arteries, to include
their origin and distal
segments, is usually a steep
LAO (50 degrees) with steep
cranial (50 degrees)
angulation

31. LCX
 The LCX is best seen in
caudal projections.
 The proximal portion of
the LCX is usually imaged
in the RAO caudal
angulation, which also lays
out the marginal arteries.
 An alternative view for the
mid segment of the LCX
and the marginal arteries is
the steep LAO caudal
(spider) view.

32. Right coronary artery angiogram

33. RCA The proximal segment of the
RCA is best seen in the flat LAO
angulation.
 For optimal visualization of the
ostium, a steep (50 degrees)
LAO projection is preferred.
 The mid segment of the RCA is
best seen in the LAO and flat
RAO projections.
 The crux, or distal RCA, and the
proximal portions of the right
PDA and PLB arteries are best
seen with an AP or slight LAO
projection with 20 to 30 degrees
of cranial angulation.
 The middle and distal segments
of the right PDA are best
visualized with a flat RAO
projection.

44. Description of coronary angiograms
• Left
• RightArtery
• LAO
• RAO
• Cranial/Caudal
Projection
• Diseased segment, percentage stenosis, length
• Calcification, thrombus, tortuousity, side branches, distal
vessel size, flow
Lesion
description
• Right/leftDominance

45. Stenosis

46. Calcification

47. Thrombus

48. Tortuousity

49. Dissection

50. Myocardial bridge

51. Flow
 TIMI grade:
 TIMI 0 flow (no perfusion) refers to the absence of any
antegrade flow beyond a coronary occlusion.
 TIMI 1 flow (penetration without perfusion) is faint
antegrade coronary flow beyond the occlusion, with
incomplete filling of the distal coronary bed.
 TIMI 2 flow (partial reperfusion) is delayed or sluggish
antegrade flow with complete filling of the distal
territory.
 TIMI 3 is normal flow which fills the distal coronary bed
completely

52. Dominance
Right Dominance Left Dominance Co- Dominance

53. Coronary anomalies
 Anomalous origin
 From same sinus
 From different sinus
 From other coronary artery
 Single coronary
 Aneurysms
 Coronary fistulas

54. Coronary anomalies

55. Coronary aneurysms

56. Graft Angiography
 JR4: Most commonly used for various grafts
 Amplatz right, LIMA catheter, dedicated bypass graft
catheters may be needed
 Clips at sites of graft may be useful guides
 Prior CTA gives valuable information
 Root angio with pigtail to identify grafts

57. Graft Angiography

58. LIMA Angiography

59. LV angiography
 Not routine nowadays
 Pigtail with contrast injection via power injector
 Done in RAO 30 to estimate LV function and mitral
regurgitation
 Assessment of LVEDP and LV to aorta gradient

60. LV Angiography
1: Basal 2: Lateral 3: Apical 4: Septal
5: Inferior
basal

61. Complications
 Local:
 Bleeding
 Hematoma
 Infection
 Pseudoaneurysm
 Compartment Syndrome
 Coronary
 Dissection, embolism, spasm

62. Complications
 Contrast related
 Contrast nephropathy
 Allergic reactions
 CHF
 Arrhythmias
 Access vessel dissection
 Stroke
 Death

63. Other coronary imaging modalities
 CTA
 MRA
 IVUS
 OCT (Optical Coherence Tomography)
 Angioscopy