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Anatomy of the coronary circulation & Angiographic VISUALIZATION Dr Sandeep Mohanan Dr Sandeep Mohanan Department of Cardiology Calicut Medical College.

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Presentation on theme: "Anatomy of the coronary circulation & Angiographic VISUALIZATION Dr Sandeep Mohanan Dr Sandeep Mohanan Department of Cardiology Calicut Medical College."— Presentation transcript:

1 Anatomy of the coronary circulation & Angiographic VISUALIZATION Dr Sandeep Mohanan Dr Sandeep Mohanan Department of Cardiology Calicut Medical College 1/10/12

2 OUTLINE Coronary arterial anatomy Variations in coronary circulation Coronary venous anatomy Angiographic views of coronary arteries

3 Coronary arterial anatomy 1 st anatomical drawings- Leonardo da Vinci Oblique inverted crown

4 The coronary arteries and their major branches are sub-epicardially located

5 Epicardial Vessel Subepicardium Subendocardium Myocardium Pericardium (Epicardium)

6 LCA ostium ~ 4mm RCA ostium~ 3.2mm

7 The LEIDEN convention Each artery arises from respective aortic sinuses - Right coronary sinus(anterior) - Left coronary sinus(left posterior) - Non-coronary sinus(right posterior) 1R2LCx pattern

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10 Right coronary artery ~ 9.8cm 1)Conus artery/ Infundibular/ Third coronary/ Adipose /Arteria of Vieussens -Separate ostium in 23% - 51% - Circle of Vieussens

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12 Right coronary artery 2) Atrial branches of the RCA - < 1mm -SA nodal artery ( Ramus crista terminalis) – 55-65%

13 Right coronary artery 3) Right ventricular branches -Acute right marginal artery -Ramus crista supraterminalis (Superior septal artery) – %, males

14 Right coronary artery 4) Posterior descending artery -Dominance -Posterior septal branches - < 15mm 5) AV nodal artery %

15 Right coronary artery 6) Postero-lateral branches to the LV - Inferior wall of the LV

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

17 Left coronary artery LMCA mm(upto 30mm) length & 3-6mm(upto 10mm diameter) -Trifurcates in 1/3rd : Ramus intermedius/ median artery/ left diagonal artery/straight LV artery -Rare variations – absent LMCA/ pentafurcation

18 Left anterior descending artery - ~ 14.7 cm ; Type I (22%), Type II & Type III diagonal branches -90deg bend after turning around P. conus as it gives off 2 nd diagonal branch -Right ventricular branches( left conal/pre-infundibular A) -~ 10 septal perforating branches (40-80mm X mm) anchors the LAD

19 LAD(contd) -1st proximal septal A is prominent (His Bundle and LBB) -Myocardial bridging – % overall (28% in children) -Rarely dual LADs

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

21 Left circumflex artery -~9.3 cm long ; mm -Left atrial branches -Kugel’s artery (Arteria anastomotica auricularis magna) -LV branches are called the Obtuse marginal arteries

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

24 Coronary segment classification system CASS investigators – 27 segments BARI – 29 segments ( ramus intermedius and 3 rd diagonal branch) - Obstructive CAD : > 50% stenosis

25 Prognostication scores Califf scoring system Gensini scoring system Candell-Riera scoring system CASS investigators: - no. of vessels - no. of proximal segments - Global LV function

26 “Dominance” A misnomer giving rise to PDA, at least 1 PLV & AV nodal A (BARI classification) - 85% right dominant -8% left dominant -7% co-dominant (70%/ 10%/ 20% – Hurst’s THE HEART) Left dominance is 25-30% in Bi-AoV Gensini GG. Coronary Arteriography. Mount Kisco,NY: Futura Publishing Co; 1975:260–274.

27 Nodal blood supply Studies on nodal blood supply principally by James (1961) and Hutchinson( 1978) - James : SA node - RCA 55% & LCA 45% AV node- RCA 90% & LCA 10% -Hutchinson : SA node - 65% & 35% AV node- 80% & 20% AV node may have dual supply in 2% cases

28 Arterial anastomoses Seen at the intracoronary/inter-coronary levels in abundance– significant in development in collaterals in CAD Most abundant at the septum Intracoronary : 1-2cm X micm Inter-coronary: 2-3 cm X micm

29 Coronary artery variations 2 coronary artery system is a recent evolutionary acquisition Fish and amphibia – 1 coronary artery Birds – ~ 40% have single coronary arteries. 1-5% of those undergoing CAG Angelini P – Coronary artery anomalies – current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines. Tex Heart Inst J 2002;29:

30 Coronary artery variations Definition of a coronary artery is not based on its origin and proximal course, but by focusing on its intermediate and distal segments/ its dependent microvascular bed. Angelini P – Coronary artery anomalies – current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines. Tex Heart Inst J 2002;29:

31 ? Coronary artery Variation vs Anomalies A broad spectrum of variations of which some may cause adverse effects Most of the coronary variations may have no clinical implications as can be proven by myocardial perfusion studies. The regional distribution of a coronary artery, The regional distribution of a coronary artery, rather than its absolute origin and characteristics.

32 Level of variables 1) Ostium 2) Size 3) Proximal course 4) Mid-course 5) Intramyocardial ramifications 6) Termination A.Anomalies without a shunt: 1. Abnormal number : 1/ 3/ 4 ostia 2. Anomalous origin: a) Outside SOV b) Independent origin from same sinus c) Opposite sinus d) Other artery 3. Myocardial bridge 4. Segmental stenosis/hypoplasia B.Anomalies with shunt: 1) Fistula 2) APOCA C. Aneurysms

33 A puzzling issue….. Proximal course of the LAD may be very different LCx may run over atrial or ventricular surface. An RCA that terminates in the AV groove well before the crux may not always be an obstruction: 7 – 10% (Grossman) Double ostia from the RCS All 3 arteries from a single sinus One single artery……………..and so on……

34 The most common coronary variation ( Cleveland Clinic-1,26,000 patients) was separate ostia for LAD & LCX – 0.41% and 2 nd commonest was LCX from RCS / RCA – 0.37% However, in another series of 1950 angiograms coronary anomalies were seen in 5.6% cases and split RCA (1.2%) was the commonest. Angelina P. Coronary artery anomalies. Philadelphia, Lippincott Williams & Wilkins, 1999.

35 Level of variables 1) Ostium 2) Size 3) Proximal course 4) Mid-course 5) Intra-myocardial ramifications 6) Termination MSCT with retrospective ECG gating is now considered the gold standard for characterization of coronary anomalies. Prompt a search for underlying CHDs 1) Shi H, Aschoff AJ, Brambs HJ. Multislice CT imaging of anomalous coronary arteries. Eur Radiol. 2004;14: ) Memisoglu E, Hobikoglu G, Tepe MS. Congenital coronary anomalies in adults: Comparison of anatomic course visualized by catheter angiography and electron beam CT. Catheter Cardiovasc Interv. 2005;66:34-42.

36 Abnormal position of ostia Coronary orifice below the cuspal margin: - 10% RCS - 15% LCS Coronaries above the sinotubular jn ~ 6% - leads to difficult cannulation, esp RCA with a high anterior ostium.

37 Abnormal number of coronary arteries Single coronary artery - Single coronary artery %, usually benign D/d- 2 separate ostia from same sinus, atresia.. Course is important – in 25% a major branch crosses the infundibulum. 3 coronaries - 3 coronaries - 1) Separate origin of conus artery from RCS (36- 50%) 2) Absent LMCA with separate ostia for LAD & LCX 4 coronaries - 4 coronaries - case reports Dual LAD % (Morettin,1976)

38 Absent LMCA ~0.4% - 1 ostia at the LCS/ 2 ostia in LCS/ 1 ostia in LCS & other RCS -Increased incidence of Left dominance -6% incidence of bridging -Not usually associated with CHDs -Similar incidence of atherosclerosis -Difficulty in selective cannulation Topaz et al. Absent left main coronary artery: angiographic findings in 83 patients with separate ostia of the left anterior descending and circumflex arteries at the left aortic sinus. Am Heart J.1991 Aug;122(2):

39 Shepherd’s-crook RCA ~5% Acute superiorly angled take-off of the RCA from the aorta. Difficult RCA lesion angioplasty Ethan Halpern. Cardiac CT. Functional anatomy.

40 Dual LAD (Duplication) ~ % of normal hearts Proximal LAD (LAD proper) bifurcates early into a short and long LAD -Type I : Short LAD in AIVS, Long LAD on prox AIVS, LV side, distal AIVS -Type II : Short LAD in AIVS, Long LAD on prox AIVS, RV side, distal AIVS -Type III: Short LAD in AIVS, Long LAD intra-myocardially in septum -Type IV: Very short LAD proper and short LAD, Long LAD from RCA Spindola-Franco H et al. Dual left anterior descending coronary artery: angiographic description of Important variants and surgical implications. Am Heart J 1983:105;445–55.

41 Coronary artery Ectasia 1 - 5% in angiographic series, more in males % are congenital Dialatation of a segment to at least 1.5times of the adjacent normal coronary artery.

42 Coronary venous anatomy Targeted drug delivery Targeted drug delivery Retrograde cardioplegia administration Retrograde cardioplegia administration Potential conduit to bypass cor. artery stenosis Potential conduit to bypass cor. artery stenosis Stem cell delivery to the infarcted region Stem cell delivery to the infarcted region Access to LA & LV myocardium for arrythmia mapping & ablation Access to LA & LV myocardium for arrythmia mapping & ablation LV epicardial pacing in CRT LV epicardial pacing in CRT

43 Coronary venous anatomy

44 THEBESIAN veins – Venae cordis minimae

45 Conventional coronary venous nomenclature Coronary sinus - Thebasian valve Anterior IV vein(Great cardiac vein) - Vieussens valves - Left marginal vein of LV - Postero-lateral LV vein Middle cardiac vein Small cardiac veins SEGMENTAL CLASSIFICATION

46 Segmental venous classification Thus 9 LV venous segments are derived which when added with the conventional classification gives the best comprehensive information to place the epicardial LV leads for CRT purposes

47 Retrograde coronary venography

48 MDCT angiogram delineating coronary veins along with arteries

49 Coronary Angiographic Views Cardiac Cath 1 st by Werner Forssman in st contrast angiography by Chavez in 1947 CART 1 st performed by F. Mason Sones in 1958 a high-resolution image-intensifier television system with digital cineangiographic capabilities. - Radiograph tube below and Image intensifier above (Flouroscopic imaging system with C-arm) - Physiologic monitoring system, sterile supplies, resuscitation equipment, Contrast injector (3-8ml/sec) and contrast media

50 Information from a CAG Information from a CAG: CAG helps visualization of the major epicardial arteries up to their 2 nd and 3 rd order branches Coronary anatomy - Coronary anatomy -Characteristics and distribution of coronary stenosis -Distal vessel size -Intracoronary thrombus -Index of coronary flow -Mass of myocardium served -Collateral vasculature Optimal injection rate: 7ml (2.1ml/s) for LCA and 4.8ml (1.7ml/s) for RCA

51 Pitfalls of CAG – A Lumenogram

52 Interpretation of the significance of a lumenogram Multiple projections from different angles, preferably orthogonal Knowledge of the normal calibre of major coronaries: LMCA: 4.5 ± 0.5 mm LMCA: 4.5 ± 0.5 mm LAD: 3.7 ± 0.4 mm LAD: 3.7 ± 0.4 mm LCX : 3.5 ± 0.5 mm ( 4.2 mm if dominant) LCX : 3.5 ± 0.5 mm ( 4.2 mm if dominant) RCA: 3.9 ± 0.6 mm ( 2.8 mm if non-dominant) RCA: 3.9 ± 0.6 mm ( 2.8 mm if non-dominant) IVUS Functional studies : FFR

53 Mistakes in CAG interpretation Inadequate number of projections used Improper/inadequate contrast injection Super-selective injection Catheter induced vasospasm Coronary artery variations Myocardial bridges Total ostial occlusions Wire induced spasm (ACCORDION EFFECT)

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55 LAO and RAO views help furnish the true PA and lateral views of the heart D/A s - foreshortening - superimposition Cranial view: Image-intensifier tilted towards head Caudal view: Image-intensifier tilted towards the feet -however the optimal angiographic view varies with coronary anatomy, body habitus and location of lesion Angiographic projections

56 Kern MJ. Cardiac Catheterization Handbook. 5 th edition,2011.

57 RAO and LAO projections

58 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.

59 RAO- LCA

60 RAO- RCA

61 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.

62 Shallow RAO cranial - LCA

63 AP cranial - LCA

64 RAO cranial - RCA

65 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.

66 RAO caudal - LCA

67 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.

68 AP (Shallow RAO) caudal- LCA

69 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.

70 LAO - LCA

71 LAO - RCA

72 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.

73 LAO cranial - LCA

74 LAO cranial - RCA

75 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.

76 LAO caudal (Spider view) - LCA

77 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.

78 Lateral view Mid & distal LAD Proximal LCX Mid RCA LIMA graft to LAD

79 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. There is no single magical projection that can be applied uniformly to all patients for visualizing a particular coronary atery

80 Panoramic coronary angiography GIORGIO TOMMASINI et al. Panoramic Coronary Angiography. JACC 31(4),March 15, 1998:871–7

81 References Hurst’s The Heart 13 th Edition Braunwalds Heart Disease 9 th edition Grey’s Anatomy Kern’s Handbook of Interventional Catheterization Kjell C Nikus. Coronary angiography. Grossman’s Textbook of Cardiac Catheterization Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976 David M Fiss. Normal coronary anatomy and anatomic variations. Applied Radiology, Jan Horia Muresian. Coronary arterial anomalies and variations. MAEDICA. A journal of clinical Medicine,1(1), Singh et al. The coronary venous anatomy. A segmental approach to aid CRT 2005, 46(1), Shilpa Bhimali et al. A STUDY OF VARIATIONS IN CORONARY ARTERIAL SYSTEM IN CADAVERIC HUMAN HEART. World Journal of Science and Technology 2011, 1(5): ISSN: 2231 – 2587.

82 Thank you


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