Will be useful for understanding coronary angiography Author- Dr Surg Capt Rajesh Pandey, VSM

2. References
Grossman’s Textbook of Cardiac Catheterization
Kern’s Handbook of Interventional Catheterization
Hurst’s The Heart 13th Edition
Braunwalds Heart Disease 9th edition
Grey’s Anatomy
Carlo Di Mario, Nilesh Sutaria. CORONARY
ANGIOGRAPHY IN THE ANGIOPLASTY ERA:
PROJECTIONS WITH A MEANING Heart
2005;91:968–976

3. Coronary Anatomy
Main coronary trunks lie in one of two orthogonal planes
Anterior descending and posterior descending coronary
arteries lie in plane of IVS
Right and circumflex coronary trunks lie in plane of AV
valves
60 LAO projection is looking down plane of IVS, with
plane of AV valves seen en face
30°RAO projection, one is looking down plane of AV
valves, with plane of IVS seen en face
Major segments and branches: BARI modification of
CASS nomenclature

7. Clinical division of RCA
Proximal - Ostium to 1st main RV branch
Mid - 1st RV branch to acute marginal branch
Distal - acute margin to crux

8. Clinical division of LAD
Proximal - Ostium to 1st major septal perforator
Mid - 1st perforator to D2 (90 degree angle)
Distal - D2 to end

9. Clinical division of the LCX
Proximal - Ostium to 1st major obtuse marginal
branch
Mid - OM1 to OM2
Distal - OM2 to end

10. Normal calibre of major coronaries
LMCA: 4.5 ± 0.5 mm
LAD: 3.7 ± 0.4 mm
LCX : 3.5 ± 0.5 mm ( 4.2 mm if dominant)
RCA: 3.9 ± 0.6 mm ( 2.8 mm if non-dominant)

11. LCA ostium ~ 4mm
RCA ostium~ 3.2mm

12. Coronary Anatomy
Right-Dominant Circulation-85%
RCA
conus branch (supplies RVOT)
AM(supply free wall of RV)
AV nodal artery, PDA-PLV (supplies inf part of IVS)

13. Left-Dominant Circulation- 8%,
PD,PLV & AV nodal all supplied by terminal portion of
LCX
Balanced-Dominant Circulation- 7%
RCA- PD
LCX- all PLV

14. Coronary Segment Classification

15. Right coronary
1, prox 2, mid 3, distal 4,PD 5, posteroatrioventricular 6,
1st PL 7, 2nd PL 8, 3rd PL 9, inferior septals; 10, AM
Left coronary
11, LM 12, prox LAD 13, mid LAD 14, distal LAD 15, 1st
diag (a, br of 1st diag) 16, 2nd diagonal,;17, septals
(anterior septals); 18, prox LCX 19, mid LCX 19a, distal
LCX 20, 21, and 22, 1st, 2nd, 3rd OM 23, left
atrioventricular; 24, 25, and 26, 1st, 2nd, 3rd, PL (in left- or
balanced-dominant system); 27, left PD (in left-
dominant system); 28, ramus (ramus intermedius); 29,
3rd Diag

16. Angiographic Views-Nomenclature
AP position Image intensifier is directly over patient with beam
traveling perpendicularly back to front (i.e., from posterior
to anterior) to patient lying flat on x-ray table
RAO position Image intensifier is on right side of patient. A, anterior; O,
oblique
LAO position Image intensifier is on left side of patient
Lt Lateral
position
Image intensifier rotated 90 deg parallel to floor
Cranial Image intensifier is tilted toward head of patient
Caudal Image intensifier is tilted toward feet of patient

21. AP caudal or shallow RAO
LMCA -entire length
Prox LAD & LCX
(branches overlapped)
After LM segment, slight
RAO or LAO angulation
may be necessary to clear
density of vertebrae
/catheter shaft

22. LAO-cranial view
LMCA (slightly foreshortened)
LAD-Septal & diagonal are
separated clearly
LCX/OM:
foreshortened/ overlapped
PD/PL of left-dominant circulation
are displayed clearly
Deep inspiration helpful
Cranial angulation permits view of
LAD/LCX bifurcation
LAO-cranial angulation that is too
steep or inspiration that is too
shallow produces considerable
overlapping with diaphragm and
liver, degrading the image

23. RAO-caudal
LMCA bifurcation
Origin & course of
LCX/OM, RI & prox LAD
seen clearly
One of the best for
visualization of LCX
LAD beyond proximal
segment obscured
Apical LAD displayed
clearly

24. RAO-cranial
Used for origins of
diagonals along mid
/distal LAD
Diagonals bifurcations
well visualized
Diagonals projected
upward
Prox LAD/LCX usually
overlapped

25. LAO-caudal (“spider” view)
LMCA (foreshortened) &
LMCA bifurcation
Prox & mid LCX with
origins of OM

26. Lateral view
Best view to show mid &
distal LAD
LAD/LCX well separated
Diagonals usually
overlapped
RI course well visualized
It best shows insertions
of bypass grafts into mid
LAD

28. LAO-cranial
Origin of RCA
Entire length of mid
RCA
PDA bifurcation (crux)
Cranial angulation tilts
PDA down to see vessel
contour / reduce
foreshortening
Deep inspiration is
necessary to clear
diaphragm

30. RAO view
Shows mid RCA & length
of PDA / PL
Septals coursing upward
from PDA, supplying
occluded LAD artery via
collaterals, may be
clearly identified
PL are overlapped, may
need addition of cranial
view

31. AP cranial
Shows origin of RCA
Mid segment
foreshortened
Best view for PD/PL of
dominant RCA system
and size of collateralized
LAD

32. Lateral view
Shows RCA origin
(especially in pt with
more anteriorly oriented
orifices) and mid RCA
PDA and PL are
foreshortened

33. Saphenous vein graft views
1. RCA graft—LAO cranial, RAO, and AP cranial
2. LAD graft (or internal mammary artery)—lateral,
RAO cranial, LAO cranial, and AP (lateral view is
especially useful to visualize anastomosis to LAD)
3. CFX (and obtuse marginal branches) grafts—LAO
caudal and RAO caudal
4. Diagonal graft—LAO cranial and RAO cranial

34. Routine Angio views
Left Coronary Artery For Concentration on Vessel Segment
Straight AP or 5 -10 deg RAO with caudal Left main
30- 45 deg LAO & 20 -30 deg cranial LAD-circumflex bifurcation
30- 40 deg RAO & 20 - 30 deg caudal Circumflex + marginal branches
5 - 30 deg RAO & 20 - 45 deg cranial LAD + diagonals
50 - 60 deg LAO & 10 - 20 deg caudal
(spider view)
LAD-circumflex bifurcation, circumflex,
marginals
Lateral (optional) Bypass conduits to LAD
Right Coronary Artery For Concentration on Vessel Segment
30 - 45 deg LAO & 15 - 20 deg cranial Proximal, mid, PDA
30 - 45 deg RAO Proximal, mid, PDA
Lateral (optional)

35. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

36. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

37. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

38. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

39. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

40. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

41. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

42. Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS
WITH A MEANING Heart 2005;91:968–976.

43. Thank you