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Slide 1 - Coronary Anatomy, Variants and Lesion Characteristics George W. Vetrovec, M.D. Medical College of Virginia Campus Virginia Commonwealth University January 2003
Slide 2 - This site has been developed solely for use by members of the Society for Cardiac Angiography and Interventions (SCA&I), henceforth referred to as "the users." The users are authorized to view, copy, download and print materials from this website subject to the following terms, conditions and exceptions: 1. The materials are to be used solely for noncommercial educational purposes directed toward students ("fellows") in interventional cardiology training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Any other use is expressly prohibited. 2. The materials are not to be reproduced or included in any way in any textbooks, journals, other enduring materials, presentations (other than described in item #1 above) without the prior written permission of the authors. 3. The materials are not to be modified. They are to be used for instructional purposes in the format provided with the source clearly identified. 4. The materials are to be used free of charge. Neither the users nor SCA&I shall charge a fee for use of these materials. 5. The materials remain the sole intellectual property of the individual contributors, who retain copyright to those materials and have granted SCA&I a license to post them on this website for the purposes described in item #1. 6. Copyright information or other proprietary notices on the materials or elsewhere on this website may not be removed, changed, or altered in any way. 7. The site design, layout and individual elements are not to be reproduced, copied or redistributed except as indicated above in item #1 above. The information on this site should not be used as a substitute for medical evaluation, advice, and/or treatment by a qualified healthcare provider. The materials are not intended for public or patient education, but rather for education of fellows in training programs as described in item #1 above. Information in text files, slides, graphs or articles on this website do not replace consultations with qualified healthcare professionals to meet medical needs. If you are not a health care provider, you should not use this site. We encourage you instead to consult a healthcare professional. The authors, contributors and editorial staff have made every effort to contact holders of copyright to obtain permission to reproduce copyright material. However, if any permissions have been inadvertently overlooked, SCA&I will be pleased to make the necessary and reasonable arrangements. If you wish to use the presentation for any purpose other than that outline above, please contact SCA&I at info@scai.org. TERMS OF USE
Slide 3 - Coronary Angiography Optimal Coronary Angiography Goal is to adequately opacify coronary artery without streaming Properly positioned catheter Sufficiently large catheter lumen for necessary and available contrast injection Always insure “reflux”
Slide 4 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 5 - Routine Angiographic Views Left Coronary Shallow RAO, AP Caudal LAO Caudal LAO Cranial RAO Cranial Right Coronary LAO Cranial AP Cranial, Shallow RAO LAO Caudal
Slide 6 - Optimal Coronary Angiographic Views: Left Main Segment Routine Adjunctive Ostial LAO Caudal AP Caudal Body RAO Caudal AP Caudal RAO Cranial Distal LAO Caudal LAO Cranial RAO Caudal
Slide 7 - Left Main: LAO Caudal
Slide 8 - Optimal Coronary Angiographic Views: Left Anterior Descending Segment Routine Adjunctive Ostial LAO Caudal AP/RAO Caudal Body RAO Caudal AP Cranial LAO&RAO Cranial Distal RAO LAO Cranial RAO Caudal
Slide 9 - LAD: RAO Cranial
Slide 10 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 11 - AP Cranial: Distal Stent Dissection
Slide 12 - LAD–Diag Lesions in the AP Cranial View
Slide 13 - AP Cranial: Distal Stent Dissection
Slide 14 - Optimal Coronary Angiographic Views: Circumflex Segment Routine Adjunctive Ostial LAO Caudal AP Caudal Body Shallow RAO AP Caudal LAO LAO cranial Distal Shallow LAO LAO Cranial Shallow RAO AP caudal
Slide 15 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 16 - Proximal Ramus Stenosis
Slide 17 - Optimal Coronary Angiographic Views: Right Coronary Artery Segment Routine Adjunctive Ostial/Prox LAO Cranial Lateral(90-110) AP Caudal Mid Vessel Shallow RAO Lateral LAO Caudal Distal Bifurcation LAO Cranial AP Cranial PDA Shallow RAO AP Cranial PLB AP caudal Lateral Cranial
Slide 18 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 19 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 20 - Optimal Coronary Angiographic Views: Vein Bypass Grafts Segment Routine Adjunctive Ostial LAD Shallow RAO AP Caudal RCA LAO LAO Caudal Body RAO LAO
Slide 21 - Optimal Coronary Angiographic Views: Bypass Graft Insertion Site SEGMENT ROUTINE* ADJUNCTIVE LAD/Diag AP Cranial Lateral Circ LAO AP Caudal RAO Cranial RCA LAO Caudal Lateral RAO Caudal PDA/PLB(Bif) AP Cranial Lateral PDA/PLB (Mid) LAO Cranial RAO Caudal *Similar Views for same area of native vessel
Slide 22 - Optimal Coronary Angiographic Views: Internal Mammary Graft SEGMENT ROUTINE ADJUNCTIVE Ostial Shallow RAO LAO Cranial Mid Vessel Shallow RAO Lateral Insertion to: LAD RAO Cranial Lateral (+/-) RCA LAO Lateral RAO Left Subclavian AP RAO Cranial
Slide 23 - Coronary Angiography Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System Type A Discrete Concentric Readily accessible Smooth Contour Little or no calcification Non ostial No major side branch involved Absence of thrombus
Slide 24 - Coronary Angiography Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System Type B Tubular Eccentric Moderate tortuosity Moderately angulated (45 – 900) Irregular contour Moderate – heavy calcification Total occlusion (< 3 months) Ostial Bifurcation lesion Thrombus present Note: B1 = characteristic only; B2 = 2 or more characteristics
Slide 25 - Coronary Angiography Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System Type C Diffuse Excessive Tortuosity Extremely angulated Total occlusion (> 3 months) Inability to protect major side branch Degenerated vein graft
Slide 26 - Coronary Angiography Distal Blood Flow/Collateral Classification Based on TIMI Trial TIMI Grade Contrast Flow 0 (No perfusion) Antegrade flow to lesion; no flow beyond occlusion 1 (Penetration with Contrast passes beyond minimal perfusion) lesion but does not opacify distal vessel during cine run 2 (Partial perfusion) Contrast passes obstruction and fills distal vessel.However, rate of filling and/or washout slower than vessel segments outside lesion 3 (Complete perfusion) Contrast passes freely into distal at same visual rate as unaffected adjacent vessels
Slide 27 - Coronary Angiography Distal Blood Flow/Collateral Classification Based on TIMI Trial Collateral Supply Contrast Flow 1 Absent 2 Minimal 3 Well developed Adapted from TIMI
Slide 28 - Coronary Angiography NHLBI Classification System for Coronary Dissection Dissection A Small radiolucent area within the lumen of the vessel B Linear, nonpersisting extravasation of contrast C Extraluminal, persisting extravasation of contrast D Spiral-shaped filling defect E Persistent lumen defect with delayed anterograde flow F Filling defect accompanied by total coronary occlusion Length (in mm) Measure end to end for type B through F dissections Staining Persistence of contrast within the dissection after washout of contrast from the remaining portion of the vessel
Slide 29 - Coronary Angiography Coronary Anomalies Common: Insignificant Conus Separate Ostium from RCA 50% Left Circ from RCA 0.3% Uncommon: Clinically Significant LM from Proximal RCA Courses between Great Vessels Associated with sudden Death
Slide 30 - Coronary Angiography Left Circumflex from RCA
Slide 31 - Coronary Angiography Left Main Arising from RCA
Slide 32 - Coronary Angiography Left Main from RCA Angulation at origin of LM Compression of LM
Slide 33 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 34 - Coronary Angiography Adapted from Seroth et al. Am J Cardiol 1990;65:891-898 LM-Right Sinus of Valsalva Septal Course
Slide 35 - Coronary Angiography Adapted from Seroth et al. Am J Cardiol 1990;65:891-898 LM-Right Sinus of Valsalva Retroaortic Course
Slide 36 - Coronary Angiography Adapted from Seroth et al. Am J Cardiol 1990;65:891-898 LM-Right Sinus of Valsalva Anterior Free Wall
Slide 37 - Coronary Angiography LM-Right Sinus of Valsalva Interarterial Course Adapted from Seroth et al. Am J Cardiol 1990;65:891-898
Slide 38 - Anomalous LM: Interarterial Course
Slide 39 - Anomalous LM: Interarterial Course
Slide 40 - Anomalous LM: Interarterial Course
Slide 41 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.
Slide 42 - Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.