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Coronary Angiogram Interpretation Dr. S.Sivasankar
Conscious sedation using a narcotic and a benzodiazepine
Vascular access: Either femoral (described in the section on vascular access and closure devices), radial, or brachial
Flush the selected diagnostic catheter with saline to ensure an air-free system
Once arterial access is obtained (as described in the section on vascular access and closure devices) a catheter of appropriate size and configuration is advanced over a 0.035 or 0.038 inch guidewire
Once in the ascending aorta, the guidewire is removed, the catheter allowed to bleed back to remove any thrombus or atherosclerotic debris
The catheter is then connected to a manifold assembly connected to a pressure transducer for continuous central pressure monitoring
The catheter is flushed to ensure an air-free system
Equipment & Technique
Zeroing and referencing: The transducer should be opened to air to zero the system. Care must be taken to ensure that the pressure transducer is at the level of phlebostatic axis, which is roughly the midportion between the anterior and posterior chest wall along the left 4th intercostal space
The central aortic pressure should be recorded and compared with the cuff measured brachial pressure. If there is considerable difference between the two, subclavian artery stenosis should be in the differential
The catheter should then be filled with 3-4 cc of contrast and advanced to engage the coronary ostium, in the LAO projection
After ensuring that there is no ventricularization or damping of the pressure, a 2 to 3 cc of contrast should be injected to confirm the position of the catheter in the coronary ostium
Technique
Coronary angiography should be performed in standard views in orthogonal planes to visualize the lesion and serve as a roadmap for PCI
Non-standard views should be considered based on the lesion location, orientation of the heart, and patient body habitus
Before injecting contrast, with every view care should be taken to ensure no ventricularization or damping of the pressure wave forms
Technique
The overall risk of major complications with coronary angiography is 1-2%. This includes death, myocardial infarction, stroke, bleeding, vascular complications and contrast reaction.
Complications
Selecting the right catheter is important and is dependent upon the following:
Access site: Choice of catheters depends to certain degree on the access site - femoral vs. radial vs. brachial
Aortic width: Normal aortic width - 3.5 to 4.0 mm; Narrow- <3.5 mm, Dilated >4.0 mm
Coronary ostial location: high vs. low; anterior vs. posterior
Coronary ostial orientation: Superior, inferior, horizontal or shepherd’s crook (for RCA only)
Standard workhorse catheters for routine coronary angiography are Judkins right size 4 (JR4) and Judkins left size 4(JL4) and the ostia are engaged in the LAO projection
Always ensure co-axial alignment of the catheter
Catheters generally have two curves: Primary (distal) curve and a secondary (proximal) curve. The distance between the two curves is the length of the catheter
Shorter curve more ideal for superior take-offs
Longer curve more ideal for inferior take-offs
Catheter Selection
If using a power injector for contrast opacification, the following settings may be considered:
RCA- 2 to 3ml/sec for 2 to 3 seconds, i.e., 3 for 6 represents a flow rate of 3ml/sec for a total volume of 6ml
LCA- 3 to 4ml/sec for 2 to 3 seconds, i.e., 4 for 8 which represents a flow rate of 4ml/sec for a total of 8ml
Ventriculography - 10 to 16ml/sec for 30 to 55ml, i.e., 13 for 39 which represents a flow rate of 13ml/sec for a total of 39ml
Common carotid artery - 8ml/sec for 10 cc
Internal carotid artery - 8ml/sec for 8cc
Vertebral artery - 7ml/sec for 7cc
Renal artery - 5ml/sec for 5 to 10cc
Iliofemoral - 7 to 9ml/sec for 70 to 120 cc
Flow Rate and Volume
Source: Baim, DS et al. Grossman’s Cardiac catheterization, angiography and intervention. Lippincott Williams & Wilkins, Philadephia
Standard Angiographic Views LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal
Best for visualizing left main, proximal LAD and proximal LCx
RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal
Best for visualizing left main bifurcation, proximal LAD and the proximal to mid LCx
Shallow RAO-Cranial view: 00 to 100 RAO and 250 to 400 cranial
Best for visualizing mid and distal LAD and the distal LCx (LPDA and LPL)
Separates out the septals from the diagonals
LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial
Best for visualizing mid and distal LAD, and the distal LCx in a left dominant system
Separates out the septals from the diagonals
Left Coronary Artery
Standard Angiographic Views PA projection: 00 lateral and 00 cranio-caudal
Best for visualizing ostium of the left main
PA-Caudal view: 00 lateral and 200 to 300 caudal
Best for visualizing distal left main bifurcation as well as the proximal LAD and the proximal to mid LCx
PA-Cranial view: 00 lateral and 300 cranial
Best for visualizing proximal and mid LAD
Left lateral view:
Best for visualizing proximal LCx, proximal and distal LAD
Also good for visualizing LIMA to LAD anastomotic site
Left Coronary Artery (other views)
Standard Angiographic Views
LAO 30: 300 LAO
Best for visualizing ostial and proximal RCA
RAO 30: 300 RAO
Best for visualizing mid RCA and PDA
PA Cranial: PA and 300 cranial
Best for visualizing distal RCA bifurcation and the PDA
Right Coronary Artery
Standard Angiographic Views An easy way to identify the tomographic views is to use the anatomic
landmarks - catheter in the descending aorta, spine and the diaphragm. The rough rules are:
RAO vs. LAO- If the spine and the catheter are to the right of the image, it is LAO and vice versa. If central, it is likely a PA view
Cranial vs. caudal - If diaphragm shadow can be seen on the image, it is likely cranial view, if not, it is caudal
Catheter and spine to the LEFT
RAO view
No diaphragm shadow
Caudal view
Catheter at the CENTER
PA view
No diaphragm shadow
Caudal view
Spine to the
RIGHTLAO view
Diaphragm shadow
Cranial view
Standard Angiographic ViewsLeft Coronary Artery
RAO 20 Caudal 20
LMLAD
Diagonal
SeptalsDistal LAD
LCx
RAO 20 Caudal 20Knowledge of the orientation of the artery
for a given view can help identify the probable path of the artery in the setting of
complete occlusion
Distal LAD fills by collaterals
LAD
Best for visualization of LM bifurcation and
proximal LAD and LCx
Standard Angiographic ViewsLeft Coronary Artery
LAO 50 Cranial 30
LM
LAD
DiagonalSeptals
Distal LAD
LCx
PA 0 Cranial 30
LM
LAD
Diagonal
Septals
Distal LAD
LCx
Best for visualization of LM proximal and mid LAD
Best for visualization of proximal and mid LAD and splaying of the septals
from the diagonals. Also ideal for visualization of distal LCx
Standard Angiographic ViewsLeft Coronary Artery
PA0 Caudal 30
LM
LADDiagonal
Septals
Distal LAD
LCx
LAO 50 Caudal 30
OM
LM
LADDiagonal
Distal LAD
LCx
OM
‘Spider’ view
Best for visualization of LM bifurcation and proximal
LAD and LCx
Best for visualization of LM bifurcation, proximal LAD and LCx
and OM
Standard Angiographic ViewsRight Coronary Artery
LAO 30
Proximal RCA
PDADistal RCA
Mid RCA
RAO 30
Mid RCA
PDA/PLV
PA 0 Cranial 30
Proximal RCA
PDADistal RCA
Mid RCA
Best for visualization of ostial and proximal RCA
Best for visualization of mid RCA and PDA
Best for visualization of distal RCA and its bifurcation
Angiogram-Interpretation A systematic interpretation of a coronary angiogram would involve:
Evaluation of the extent and severity of coronary calcification just prior to or soon after contrast opacification
Lesion quantification in at least 2 orthogonal views:
Severity
Calcification
Presence of ulceration/thrombus
Degree of tortuosity
ACC/AHA lesion classification
Reference vessel size
Grading TIMI flow ( Thrombolysis In Myocardial Ischemia)
Grading TIMI myocardial perfusion blush grade
Identifying and quantifying coronary collaterals
ACC/AHA Lesion Classification Type A Lesion: Minimally complex, discrete (length <10 mm), concentric, readily accessible, non-angulated segment (<45°), smooth contour, little or no calcification, less than totally occlusive, not ostial in location, no major side branch involvement, and absence of thrombus
Type B Lesion: Moderately complex, tubular (length 10 to 20 mm), eccentric, moderate tortuosity of proximal segment, moderately angulated segment (>45°, <90°), irregular contour, moderate or heavy calcification, total occlusions <3 months old, ostial in location, bifurcation lesions requiring double guidewires, and some thrombus present
Type C Lesion: Severely complex, diffuse (length >2 cm), excessive tortuosity of proximal segment, extremely angulated segments >90°, total occlusions >3 months old and/or bridging collaterals, inability to protect major side branches, and degenerated vein grafts with friable lesions.
Source: Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiology. 1988;12:528-45
Other Definitions Lesion length: Measured “shoulder-to-shoulder” in an unforeshortened view
Discrete Lesion length < 10 mm
Tubular Lesion length 10–20 mm
Diffuse Lesion length ≥ 20 mm
Lesion angulation: Vessel angle formed by the centerline through the lumen proximal to the stenosis and extending beyond it and a second centerline in the straight portion of the artery distal to the stenosis
Moderate: Lesion angulation ≥ 45 degrees
Severe: Lesion angulation ≥ 90 degrees
Calcification: Readily apparent densities noted within the apparent vascular wall at the site of the stenosis
Moderate: Densities noted only with cardiac motion prior to contrast injection
Severe: Radiopacities noted without cardiac motion prior to contrast injection
TIMI Flow Grades
TIMI 0 flow: absence of any antegrade flow beyond a coronary occlusion
TIMI 1 flow: (penetration without perfusion) faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed
TIMI 2 flow: (partial reperfusion) delayed or sluggish antegrade flow with complete filling of the distal territory
TIMI 3 flow: (complete perfusion) is normal flow which fills the distal coronary bed completely
Gibson CM, et al. Am Heart J. 1999;137:1179–1184
TIMI Myocardial Perfusion Grades Grade 0: Either minimal or no ground glass appearance (“blush”) of the myocardium in the distribution of the culprit artery
Grade 1: Dye slowly enters but fails to exit the microvasculature. Ground glass appearance (“blush”) of the myocardium in the distribution of the culprit lesion that fails to clear from the microvasculature, and dye staining is present on the next injection (approximately 30 seconds between injections)
Grade 2: Delayed entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) of the myocardium that is strongly persistent at the end of the washout phase (i.e. dye is strongly persistent after 3 cardiac cycles of the washout phase and either does not or only minimally diminishes in intensity during washout).
Grade 3: Normal entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) of the myocardium that clears normally, and is either gone or only mildly/moderately persistent at the end of the washout phase (i.e. dye is gone or is mildly/moderately persistent after 3 cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout phase), similar to that in an uninvolved artery.
Gibson CM, et al. Circulation. 2000;101:125-130
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