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Coronary Angiogram
Jae
-Hwan Lee
Jae-Hwan
Cardiovascular Center,
Chungnam National University Hospital,
Daejeon, Korea
Coronary Anatomy
Branch to SA node
(SVC branch)
Anterior
RA branch
of RCA
Sternocostal surface
Interpretation of Coronary Angiogram
Coronary Anatomy
Branch to SA node
(SVC branch)
Oblique vein of LA
(Marshall)
Great cardiac vein
SA node
PL branch
Coronary sinus
Right coronary artery
Posterior
descending
artery
RV branch
Obtuse marginal
(OM) branch
Posterior vein
of LV
Middle
cardiac vein
Diaphragmatic surface
Interpretation of Coronary Angiogram
PD
A
Interpretation of Coronary Angiogram
Course
- Right-dominant system (85%)
Down right AV groove toward crux of the heart,
gives off PDA from which septals arise, continues
in left AV groove giving off PL branches.
Supplies to LV
- 25-35% of LV
Interpretation of Coronary Angiogram
SA Nodal Artery
nd branch of RCA
- Usually 2nd
- Courses obliquely backward through upper portion
of atrial septum and anteromedial wall of the RA
- Supplies SA node, RA and sometimes LA
Interpretation of Coronary Angiogram
AV Nodal Artery
- Arises at or near crux; Supplies AV node
OM
l
a
t
ep
x
LC
L AD
S
LMCA
2
M
O
Di
al
on
ag
Interpretation of Coronary Angiogram
Optimal Views
- Caudal views might be the best to evaluate LMCA and
both LAD and LCx ostia
- Shallow LAO cranial view for ostial evaluation
- Sometimes, RAO cranial will be helpful for ostial LAD
evaluation
Interpretation of Coronary Angiogram
10
Branches
- Septals; root-like, intramyocardial, less movement
- Diagonals; supply lateral LV, anterolateral papillary m.
- 1/3 have ramus intermedius (RI)
LV Supplies
- 45~55% of LV; anterolateral, apex, and septum
Interpretation of Coronary Angiogram
11
Branches
- Obtuse marginal; lateral free wall of LV
LV Supplies
- 15~25% of LV
- 40~50% in dominant LCx system
Interpretation of Coronary Angiogram
12
13
14
LAO view
Interpretation of Coronary Angiogram
15
16
PL
RAO view
Interpretation of Coronary Angiogram
17
Caudal View
Interpretation of Coronary Angiogram
18
Cranial View
Interpretation of Coronary Angiogram
19
20
RAO Caudal
21
AP Caudal
22
23
RAO Cranial
24
AP Cranial
25
LAO Cranial
26
Lesion Description
27
Lesion Description
Number of vessels diseased
>50% DS in Five major vessels >2mm diameter
- LAD LAD, Dx, Septal, RI
- LCx LCx, OM
- RCA RCA, RV, PDA, PL
- LMCA
- Graft LIMA, SVG, GEA, RA
Ex) LAD + OM 2 VD
LMCA disease 2 VD
LMCA + mRCA 3 VD
LAD + Small PCA (=1.0mm) 1 VD
Interpretation of Coronary Angiogram
28
Lesion Description
Lesion length
- Discrete: <10 mm in length
- Tubular: 10~20 mm in length
- Diffuse: >20 mm in length
Eccentricity
- Concentric; 50%
- Eccentric; side 25%
Concentric
Interpretation of Coronary Angiogram
Eccentric
29
Lesion Description
Arrangement of the lesions
- Tandem; two lesions located within one balloon length
- Sequential; two lesions located at a distance longer
than the balloon
Contour
- Smooth vs. Irregular
- Ulceration; lesions with a small crater consisting of a
discrete luminal widening in the area of stenosis
30
Lesion Description
Proximal vessel tortuosity (accessibility)
Number of >75 bends to reach the lesion
- None
- Mild; one bends
- Moderate; two bends
- Severe; three bends
Lesion angulation
- None/Mild; lesion located on a straight segment or a
bend <45
- Moderate; 45~90 bend
- Severe; bend >90
Interpretation of Coronary Angiogram
31
Lesion Description
Calcification
- None
- Mild; densities noted only after contrast injection
- Moderate; densities noted only with cardiac motion
prior to contrast injection
- Severe; radiopacities noted without cardiac motion
prior to contrast injection
Thrombus
- Discrete, intraluminal filling defect is noted with defined
borders and is largely separated from the adjacent wall
- Contrast staining may or may not be present
Interpretation of Coronary Angiogram
32
Lesion Description
Ostial lesion
Origin of the lesion 3mm of the vessel origin
- Aorto-ostial; aortic junction (LMCA, pRCA)
- Branch-ostial; aorta major
epicardial artery
LAD & LCx os
Dx os
OM os
PDA and PL os
33
Lesion Description
Chronic total occlusion (CTO)
TIMI 0 or 1
- Duration; usually more than 3 months
; defined by clinical history (Sx onset, MI, )
Favorable
Interpretation of Coronary Angiogram
Unfavorable
34
Lesion Description
Collateral channels in RCA occlusion
35
Lesion Description
Collateral channels in LAD occlusion
36
Lesion Description
Collateral channels in LCx occlusion
37
Lesion Description
Bifurcation lesion
38
Safian Classification
Type I
Parent vessel stenosis
proximal and distal to
bifurcation
Type II
Parent vessel stenosis
proximal to bifurcation
Type III
Parent vessel
stenosis distal to
bifurcation
Type IV
Parent vessel normal,
ostial side branch
stenosis
Interpretation of Coronary Angiogram
39
Duke Classification
Type A
Type B
Type C
Type D
Stenosis involving the
parent vessel and the
ostium of the side
branch
Interpretation of Coronary Angiogram
Type E
Type F
Stenosis discretely
involving the parent
vessel and ostium of
the side branch
40
Type 2
Lesions located only in the main branch, proximal and
distal, and not the ostium of side branch
Type 3
Lesions located in the main branch
proximal to the bifurcation
Type 4
Only the ostium of each branch of the
bifurcation involved with no proximal disease
Type 4a
Type 4b
41
Medina Classification
0,1
MB
(Distal)
MB
0,1
SB
(Proximal)
0,1
1,1,1
1,0,0
1,1,0
1,0,1
0,1,0
0,1,1
0,0,1
42
Lesion Description
Low Risk
Moderate Risk
High Risk
Discrete
Tubular
Diffuse
Concentric
Eccentric
Excessive tortuosity of
Readily accessible
Nonangulated (<45)
Smooth contour
Irregular contour
proximal segment
bridging collaterals
Ostial in location
Absence of thrombus
friable lesions
43
Lesion Description
Lesion Type (AHA/ACC)
Type A
- lesion with only low risk
Type B1
- lesion with only one moderate risk
Type B2
- lesion with two or more moderate risk
Type C
- lesion with at least one high risk
Interpretation of Coronary Angiogram
44
45
Focal narrowing
Diffuse narrowing
46
47
Mistakes in Interpretation
48
Case Study
49
Anatomic Variants
Anomalies of origin
- High take-off
- Multiple ostia
- Single coronary artery
- Anomalous origin from pulmonary artery
- Origin from systemic vessels
Anomalies of origin & course
- Origin of coronary artery from opposite sinus (ACAOS)
- Course between great vessels
Anomalies of course
- Myocardial bridge
- Duplication of arteries
Anomalies of termination
- Coronary artery fistula
- Coronary arcade
- Extracardiac termination
50
AL
AL engagement
engagement
Interpretation of Coronary Angiogram
51
Anomalous
Anomalous origin
origin of
of Coronary
Coronary Artery
Artery from
from Opposite
Opposite Sinus
Sinus (ACAOS)
(ACAOS)
EBU
EBU or
or JL
JL engagement
engagement
Interpretation of Coronary Angiogram
52
LCx
LCx
Aorta
Aorta
PA
PA
RCA
RCA
LAD
LAD
56/M,
56/M, Atypical
Atypical chest
chest pain
pain
Interpretation of Coronary Angiogram
53
67/M,
67/M, Stable
Stable angina
angina
Interpretation of Coronary Angiogram
LMCA-pLAD
LMCA-pLAD cross
cross over
over
54
FU
FU angiogram
angiogram
Interpretation of Coronary Angiogram
55
56
57
70/M,
70/M, Unstable
Unstable angina
angina
Interpretation of Coronary Angiogram
58
59
60
Superdominant
Superdominant RCA
RCA
Interpretation of Coronary Angiogram
61
12-years-old boy
Exertional chest pain with syncope for 3 yrs
Chest pain and shock during treadmill test
Peak CK / CK-MB = 893 / 23.4 IU/L
62
Resting
EKG
63
Postexercise
EKG
64
Postexercise
EKG
65
Admission Date
66
67
Posterior
MV
TV
N
L
R
PA
Anterior
TEE Findings
Interpretation of Coronary Angiogram
68
AP Caudal
69
PA
R
TV
PA
TV
MV
L
MV
Rest
Exercise
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
Myocardial Bridging
86
Myocardial Bridging
Myocardial Bridging
88
90
91
Thrombi suction
92
Final
93
94
pLAD balloon
Interpretation of Coronary Angiogram
95
After stenting
Interpretation of Coronary Angiogram
96
97
98
99
100
101
102
103
32/F, NSTEMI
Interpretation of Coronary Angiogram
105
Dissection?
106
45/F, NSTEMI
107
45/F, NSTEMI
108
109
FU angiogram
Interpretation of Coronary Angiogram
110