Coronary Angiographic Views
Coronary Angiographic Views
Discussion on coronary angiographic views.
Coronary angiography is done in multiple projections or views to get a three-dimensional idea of the coronary lesions. Some regions of the coronary arteries may appear foreshortened in certain views so that true length of the lesion may not be appreciated.
Actual severity of eccentric stenosis can be ascertained only by multiple orthogonal views. Even though there are several conventional views for coronary angiography, unusual angulations may be needed in an individual case to guide coronary interventions. Often a test shot is given before the actual cine run to see if the branches are overlapping or not.
Common projections used in coronary angiography are left anterior oblique (LAO), right anterior oblique (RAO), postero-anterior (PA or AP), and lateral views. In addition to these, varying degrees of cranial or caudal angulations can be added to these views. In general, proximal parts of the major vessels are best seen in caudal projections.
Content
0.32 -> Discussion on coronary angiographic views.
22.48 -> Coronary angiography is done in
multiple projections or views
26.8 -> to get a three-dimensional idea of the coronal
lesions. Some regions of the coronary arteries
32.72 -> may appear foreshortened in certain views so that
true length of the lesion may not be appreciated.
40.48 -> Actual severity of eccentric stenosis can be
ascertained only by multiple orthogonal views.
48.32 -> Even though there are several conventional
views for coronary angiography,
52.72 -> unusual angulations may be needed in an individual
case to guide coronary interventions. Often a
59.84 -> test shot is given before the actual cine run
to see if the branches are overlapping or not.
67.2 -> Common projections used in coronary
angiography are left anterior oblique (LAO),
73.76 -> right anterior oblique (RAO), postural
anterior (PA or AP) and lateral views. In
81.36 -> addition to these, varying degrees of cranial or
chordal angulations can be added to these views.
88.24 -> In general, proximal parts of major vessels
are best seen in caudal projections.
95.92 -> We will discuss the views for
left coronary angiography now.
102.32 -> Spider view or LAO caudal view is often the
first view taken during coronary angiography.
109.44 -> This view is useful in visualizing the left
main coronary artery and its bifurcation
115.52 -> into left and anterior descending coronary
artery and left circumflex coronary artery.
121.6 -> LAO angulation may vary from 40 to 50 degrees
and caudal angulation 25 to 40 degrees.
129.12 -> LAO caudal view of left coronary angiogram
resembles a spider and hence the term spider view.
136.08 -> LMCA: left main coronary artery, LCX: left
circumflex coronary artery lesion. Lesion in
143.36 -> LCX marked by yellow arrow. LAD: left and
right descending coronary artery, early OM:
150 -> early obtuse marginal branch of the LCX. From
the LMCA bifurcation a LAD is seen towards the
156.8 -> catheter side and LCX towards the opposite side.
In this view dye or contrast reflux into the aorta
164.08 -> from the LMCA is seen. Absence of dye reflux would
mean left main ostial disease or rarely spasm.
172.64 -> This is a left coronary angiogram in
LAO caudal view in another case. JL:
178.48 -> Judkins left coronary catheter. Difference
in the orientation of coronaries
183.6 -> could be due to anatomical variations
as well as mild changes in angulations
189.28 -> used. X-ray penetration will be less in LAO
caudal view especially in obese individuals.
196.72 -> In this view mid segment of a LAD is foreshortened
and hence this view should not be used during
203.28 -> angioplasty of mid LAD. But proximal region of
LAD is visualized well proximal and mid segments
211.12 -> of LCX are well seen in this view.
Video of left coronary angiogram
216.64 -> in a LAO caudal view is shown here with
annotation of branches in a still frame.
236.56 -> RAO caudal view is another common
view for the left coronary angiogram.
241.28 -> Some operators use this as the first view. Usual
angulation is 30 to 40 degrees to the right.
248.96 -> But shallower views may be used sometimes to
reduce respiratory movements. Sufficient caudal
255.68 -> angulation to separate out the proximal
portions of the LAD and LCX is used.
261.84 -> Proximal and mid portions of LCX and
bifurcation of marginal branches are seen.
268.24 -> It is a good view for the distal LAD.
Diagonal and septal branches may superimpose
273.84 -> on the proximal and mid LAD in this view.
Left coronary angiogram in RAO caudal view
280.56 -> showing a tight lesion in the obtuse marginal
branch of the left circumflex coronary artery.
286.16 -> LAD: left anterior descending coronary artery. The
OM lesion is marked by the blue arrow and is seen
293.28 -> in the proximal portion of the obtuse marginal,
which is a major branch of the left circumflex.
298.96 -> This is a left coronary angiogram in RAO caudal
view from another case. Distal LAD is seen well
306.16 -> in this case. Diagonal and septal branches are
overlapping the mid LAD as mentioned earlier.
314.32 -> PA cranial view is ideal for most lesions
in the proximal and middle LAD. A cranial
320.32 -> angulation of 40 degrees shows the diagonal
and septal branches in opposite directions
326.08 -> well separated from the LAD.
Left coronary angiogram in PA cranial view
331.68 -> showing a proximal block marked by an arrow in
LAD, in this case a recanalized vessel after
337.84 -> anterior wall myocardial infarction. Septal and
diagonal branches of LAD are also seen. Almost the
344.8 -> whole extent of the LAD is seen well. Proximal
left circumflex is foreshortened in this view.
351.2 -> Rightward angulation, RAO cranial is useful
in reducing the overlap of proximal LAD
357.76 -> by the vertebral spine and the catheter. It may be
noted that in both cranial views the diaphragmatic
364.16 -> shadow goes high up into the field.
Video of left coronary angiogram in
369.44 -> RAO cranial view showing a complex lesion in the
LAD. The LAD can be seen wrapping around the apex,
377.84 -> type 3 LAD. In type 1, LAD it will stop short of
the apex and type 2 will reach up to the apex.
389.6 -> LAP cranial view straightens out the proximal and
mid LAD. Diagonal branches are seen on the same
396.96 -> side as the obtuse marginal branches. Septal
perforators are seen to the opposite side.
403.84 -> In this left coronary angiogram in LAO cranial
view, OM branches of LCX are seen overlapping
410.96 -> the spine. Diagonals are seen running down between
the spine and the LAD. Septal branches are seen on
418.32 -> the opposite side but almost parallel to the LAD.
Lateral view is seldom used and ideally requires
425.92 -> the positioning of the hands above the head
to avoid superimposition of patient's arms.
432.4 -> But this requirement is not there when the
field of interest is in the digital part of
437.04 -> the LAD which is anterior. The same applies to
visualization of the anastomosis between the
444.24 -> left internal mammary artery and LAD.
LIMA to LAD coronary bypass graft in lateral view.
451.92 -> The image has been darkened a bit by post
processing to visualize the LIMA and LAD well.
458.56 -> Since it was an injection into the left
subclavian artery just near the LIMA ostium,
464.08 -> the contrast density was a bit lower than
that of a super selective LIMA injection.
469.76 -> The sternal wires indicate the post sternotomy
status. Distal flow into the LAD is good.
476.8 -> Retrograde flow from the anastomotic site
into the proximal part of LAD is also seen.
485.04 -> Now we will move on to views
for right coronary artery.
491.04 -> RAO view shows the conus branch and sinus node
artery in opposite directions as seen in this
497.68 -> image. Right ventricular branches and posterior
descending artery are seen well. Multiple septal
504.16 -> branches can be seen arising from the PDA.
PDA has a mild lesion in the proximal portion.
510.64 -> In the angiogram illustrated the posterior left
ventricular branch is occluded and only a stump,
517.28 -> PLV stump, is seen. Atrioventricular nodal
artery usually originates near the bifurcation
523.52 -> of the right coronary artery into PDA and PLV.
Here is another right coronary angiogram in
529.68 -> RAO view. Here the septal branches of PDA and
PLV are seen well. RAO view shows the proximal
537.12 -> part of the right coronary artery in a vertical
line. RAO view is identified with the spine seen
543.68 -> on the right side. Tight stenosis is seen just
before the origin of right ventricular branch.
550.72 -> LAO view usually shows the full length
of the right coronary artery in a C
555.6 -> shape. Distally the right coronary artery divides
into PDA and PLV at the crux cordis. Crux cordis
564.16 -> is the junction of the atrioventricular and
interventricular ventricular grooves posteriorly.
569.44 -> The artery which crosses the crux is defined
as the dominant coronary artery. Right coronary
575.84 -> dominance is much more common than left dominance.
Even when the right coronary artery is dominant
582.56 -> the major portion of left ventricular myocardium
is supplied by the left coronary artery.
588.56 -> PA cranial view of right coronary angiogram
is shown here. As in other cranial views
594.96 -> diaphragmatic contour can be seen high up in
the field. A tight lesion is seen in proximal
601.28 -> portion of PDA, marked as one. PLV: posterior left
ventricular branch, AM: acute marginal branch,
610.08 -> RCA: right coronary artery. Conus: conus branch
of the right coronary artery. Sometimes while
617.2 -> cannulating the right coronary artery the catheter
slips into the conus artery. This causes wedging
623.92 -> and damping of catheter tip pressure. Prolonged
inadvertent injection of contrast into the conus
630.24 -> branch can cause ventricular tachycardia or
ventricular fibrillation occasionally. A large
636.32 -> conus branch crossing the right ventricular
outflow tract can cause problem during
641.44 -> intra cardiac repair of tetralogy of Fallot.
LAO cranial view of right coronary angiogram
647.84 -> using an Amplatz right catheter is shown
here. This RCA was difficult to calculate
654.16 -> with Judkins right catheter even after repeated
attempts. The angiogram shows only minimal
661.12 -> luminal irregularities of the RCA. Right
ventricular branches are seen originating
666.72 -> from the proximal region. Terminal branching
of RCA into posterior left ventricular
672.96 -> (PLV or PLB) branches and posterior
descending coronary artery are also seen.
Source: https://www.youtube.com/watch?v=m1NnkEL6fFg