Coronary Angiography

1. Coronary Angiography
27-08-2015
Dr. Y. Madhu Madhava Reddy

2. Coronary angiography remains the gold
standard for detecting clinically significant
atherosclerotic coronary artery disease
The technique was first performed by Dr.
Mason Sones at the Cleveland Clinic in 1958
Coronary Angiography

3. To visualize coronary arteries, branches,
collaterals and anomalies
Precise localization relative to major and minor
side branches, thrombi and areas of calcification
To visualize vessel bifurcations, origin of side
branches and specific lesion characteristics
(length, eccentricity, calcium etc)
Goals

4. Coronary artery
Coronary artery is a vasa
vasorum that supplies the
heart.
Coronary comes from the
latin ”Coronarius”
Meaning “Crown”.
4

5. Coronary artery
• The coronary artery arises just
superior to the aortic valve and
supply the heart
• The aortic valve has three cusps –
#left coronary (LC),
#right coronary (RC)
#posterior non-coronary (NC)
cusps.
5

6. Right coronary artery
• Originates from right
coronary sinus of
Valsalva
• Courses through the
right AV groove
between the right
atrium and right
ventricle to the inferior
part of the septum
6

7. Branches of RCA
7
Right coronary artery
Conus artery
Sinu nodal artery
Marginal artery
Post. Descending IV artery
AV nodal artery-
Conus branch
SINU NODAL BRANCH
AV Nodal Branch

8. • Conus branch – 1st branch supplies the RVOT
• Sinus node artery – 2nd branch - SA node.(in 40%
they originate from LCA)
• Acute marginal arteries-Arise at acute angle and runs
along the margin of the right ventricle above the
diaphragm.
• Branch to AV node
• Posterior descending artery : Supply lower part of the
ventricular septum & adjacent ventricular walls.
Arises from RCA in 85% of cases.
8

9. Area of distribution
RT CORONARY ARTERY
1)Right atrium
2)Ventricles
a) greater part of rt. Ventricle except the area adjoining the
anterior IV groove.
b) a small part of the lt. ventricle adjoining posterior IV
groove.
c)Posterior part of the IV septum
d)Whole of the conducting system of the heart, except part
of the left branch of AV bundle
9

10. Left coronary artery
• Arises from left coronary
cusps
• Travels between RVOT
anteriorly and left atrium
posteriorly.
• Almost immediately
bifurcate into left anterior
descending and left
circumflex artery.
• Length – 10-15mm
10

11. Left coronary
artery
LAD
Diagonal artery
Lt Conus artery
Anterior Septal
br
Circumflex
artery
Obtuse marginal
branches
Ventricular
branches
Atrial rami
11

12. LT CORONARY ARTERY DISTRIBUTION
1) Left atrium.
2) Ventricles
i) Greater part of the left ventricle, except the area
adjoining the posterior IV groove.
ii) A small part of the right ventricle adjoining the anterior
IV groove.
iii) Anterior part of the IV septum.
iv) A part of the left br. Of the AV bundle.
12

13. DOMINANCE
• Determined by the arrangement that which artery
reaches the crux & supply posterior descending
artery
• The right coronary artery is dominant in 85% cases.
• 8% cases - - circumflex br of the left coronary artery
• 7% both rt & lt coronary artery supply posterior
IVseptum & inferior surface of the left ventricle-here
it is balanced dominance.
13

14. Normal coronaries (LCA)

15. Normal coronaries (RCA)

16. CORONARY ANGIOGRAPHY

17. INDICATION
1. Diagnosis of CAD in clinically suspected pts.
2. Providing peri-interventional information for
percutaneous coronary intervention
3. Coronary anomalies
4. To exclude stenoses before non-coronary cardiac
surgery (valve surgery after 40 yrs of age)
5. Determine patency of coronary artery bypass grafts
17

18. INDICATIONS
 In patients with non–ST-segment elevation acute
coronary syndromes with high-risk features (e.g.,
ongoing ischemia, heart failure)
 In patients with acute ST-segment elevation myocardial
infarction (STEMI)
 Primary percutaneous intervention (PCI) is usually
performed in the same procedure, immediately after
the diagnostic procedure

19. CONTRAINDICATIONS
 Coagulopathy
 Decompensate congestive heart failure
 Uncontrolled Hypertension
 CVA
 GI Hemorrhage
 Pregnancy
 Inability for patient cooperation
 Active infection
 Renal Failure
 Contrast medium allergy
19

20. Before the Procedure
• After patient is properly identified, the
procedure must be explained before consent
can be signed
• Baseline vital signs will be done and as long as
these are within the doctor’s interest, can
proceed with the procedure
• Blood tests must be done including BUN,
creatnine, PTT, INR, insulin/sugar levels

21. Patient Prep
• After patient is put on table, the area being
puncture must be free from hair
• Hair removal done by disposable electric razor
and removed by sticky side of cloth tape
• Patient must be surgically cleaned with
hospital approved sterile surgical prep
solution

22. Sterile Field and Patient
• The technologist working with the cardiologist
must be scrubbed in following basic sterile
surgical technique
• The patient is then draped from neck down
with sterile drapes
• All equipment (radiation shields, image
intensifier, equipment used to manipulate
machine) must be prepped with sterile covers

23. Sterile equipment needed
Procedure tray should include:
-sterile gowns and gloves for scrub
tech and doctor
-sterile towels and drapes for
procedure
-equipment covers
-gauze
-scalpel, needles, scissors, hemostats
-syringes for heparin/saline flush,
lidocaine, and blood draw
-labels with marking pen for any item
filled with a solution
-basin for heparin/saline mixture,
basin for waste fluids, small cup for
lidocaine
-skin prep solution
-high power manifold
-connection tubing
Fig. 2

24. Catheters, wires and sheaths
Fig. 3
-Three catheters are used: JR4 (advances to right coronary arters, JL4 (advances to left coronary
arteries), and 145 degree pigtail catheter (to advance into ventricles
-One 135cm wire
-Sheath corresponds with catheter size (5F cath gets 5F sheath etc.)
-Size of catheter depends on doctor’s preference but generallly 6F is used

25. Medications Used
• Patient relaxed with Versed or Fentanyl,
sometimes both
• Two 500mL bags of saline infused with 2,000
units (2cc) heparin each for flushing all tubing,
catheters, sheaths
• Lidocaine for tissue numbing
• Visipaque contrast unless otherwise specified

26. START PROCEDURE
When doctor and tech are scrubbed and all equipment and supplies are
ready, the procedure may begin

27. Arterial Puncture
• Access is easiest from right side of
patient due to aortic bend
• Puncture is generally done via the
femoral artery
• Alternative sites include the radial and
brachial arteries of the arm

28. Catheter introduction
After puncture of femoral, radial or brachial artery (primarily on right side of
patient), a catheter is advanced into the aorta and then the coronary arteries

29. Steps to Insert Catheter
• After numbing the groin area, the femoral
artery is palpated and a needle is inserted in
that direction
• When blood comes out of needle, the artery
has been accessed
• A small, flexible guidewire is then inserted
into the lumen of the needle
• The needle can then be removed but the wire
must maintain position

30. Inserting Catheter
• After removing the needle, a flexible plastic
tube can be placed over the wire and
introduced into the artery. This is called a one-
way sheath (allows insertion of catheters and
wires without blood escaping)
• The catheter is then inserted over the
guidewire but through the sheet and
advanced into placement to the aorta.
• MC Catheter used is Judkins.

31. Catheter Placement
• Movement of catheter is monitored under
fluoroscopy with the cardiologist manipulating
its movements
• The fluoroscopic machine is manipulated by a
qualified, scrubbed in, radiologic technologist
• When catheter is in place, wire can be
removed and contrast administered

32. Catherization

34. Important safety aspects
• It is essential that the catheter tip does not
wedge into a narrow coronary ostium and cause
occlusion of flow.
• The catheter tip must be axially oriented in
proximal vessel rather than being angulated
against the side wall, which may cause intimal
damage.
• Contrast injection with catheter tip impacted to
side wall of coronary artery can cause osital
dissection.
• Above mentioned are the fatal complications.

35. Contrast Media
• Contrast media-Low osmolarity, Non-ionic
• Dose-3-10 ml;320-370 mg of iodine/mg, using a
hand-held syringe filled from a reservoir.
• Left coronary artery is filled with 6-8 ml, right
coronary artery is filled with 3-5 ml usually
35

36. Angiographic projection
• The heart is oriented obliquely in the thoracic cavity,
the coronary circulation is generally visualized in the
RAO & LAO projection to furnish true PA & LAT views
of the heart. using both cranial & caudal angulations.
• For LCA branches, views -
-AP ,RAO, LAO with cranial tilt
• For RCA branches, views reqd. are
-AP,RAO ,LAO ĉ or ĉout cranial

38. 38
Angiographic view of LCA

39. Angiographic view of RCA 39

40. Pitfalls of coronary angiography
1. Inadequate vessel opacification- May give
impression of ostial stenoses, missing side branches or
thrombus.
2. Eccentric stenosis- Coronary atherosclerosis often
leads to eccentric or slit–like narrowing than central
narrowing; so if the long axis of the vessel is projected,
the vessel may appear to have a normal or near normal
caliber.
3. Superimposition of branches
4. Foreshortening of the stenotic segment due to
projectional defect
40

41. Rotational CA
• X-ray system rotates around the patient during the
acquisition of a single run
• Significant reduction in both contrast agent usage and
radiation dose of up to 30%, without compromising
image quality
• Contrast medium is injected automatically (3 mL /s for
the LCA and 2 mL/s for the RCA) range 12-18 cc
• After this preload, rotation of the C-arm was started
automatically and X-rays taken
41

42. Possible complications
• Femoral : Dissection of femoral / iliac artery or
aorta , Haematoma
• Aorta : Damage to aortic intima , Embolus to
head and neck vessels, aortic root dissection.
• Coronary : Ostial dissection, coronary embolus,
arrhythmia due to catheter wedging or contrast
medium, spasm due to catheter or contrast
medium.
• General : Hypotension, left heart failure –
contrast overload, Contrast allergy

43. 43
Tight stenosis noted involving the
mid segment of right coronary
artery. Distal branches are normal.
A partially obstructive
narrowing noted in the
proximal segment of the
LAD

47. Left main stem stenosis

48. Muscle Bridge

52. Pigtail catheter
in left ventricle
to measure
ventricular
pressure
Aortagram
used to assess
ascending and
descending
aorta

53. Fluoroscopy machine
• The x-ray machine is suspended from the
ceiling. It can be manipulated in multiple
angles and views to achieve a desired picture.
The x-ray comes from the bottom of the
machine and the image intensifier that
transmits the image is above the patient.
Lead shielding and a radiation badge is
required for all personnel in the room during
the procedure.

56. Finished Procedure
• The procedure is complete when the
radiologist or cardiologist has seen all the
views and anatomy desired and all pressures
recorded.
• The catheter can be removed and manual
pressure must be applied to entry site for 15
minutes.

57. Post Procedure Instructions
• The patient must lie flat and supine for a
minimum of two hours to ensure the artery
does not reopen.
• Dressing must remain dry, no lifting over five
pounds for three days.
• No shower for 24 hours.

58. Cardiac Catheterization

59. Thank you