1. Sripal Bangalore, M.D., M.H.A. Deepak L. Bhatt, M.D., M.P.H., F.A.H.A
Coronary Angiography
Sripal Bangalore, M.D., M.H.A.
and
Deepak L. Bhatt, M.D., M.P.H., F.A.H.A

2. Overview Coronary Angiography Indications Contraindications / Caution
Equipment
Equipment & Technique
Precautions
Pressure monitoring
Zeroing and Referencing
Guide catheter selection
Flow rate and volume
Standard angiographic views
Angiogram- interpretation
ACC/AHA lesion classification
Other definitions
TIMI flow and perfusion grades
Congenital coronary anomalies

3. Indications
Known or suspected CAD (Class I and III only) I I I I I I I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
CCS class III and IV angina on medical treatment
High-risk criteria on noninvasive testing regardless of anginal severity
Patients who have been successfully resuscitated from sudden cardiac death or have sustained (>30 seconds) monomorphic ventricular tachycardia or non-sustained (<30 seconds) polymorphic ventricular tachycardia
Angina in patients who are not candidates for coronary revascularization or in whom revascularization is not likely to improve quality or duration of life
As a screening test for CAD in asymptomatic patients
After CABG or angioplasty when there is no evidence of ischemia on noninvasive testing
Coronary calcification on fluoroscopy, electron beam computed tomography, or other screening tests without criteria listed above B A B C C C C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

4. Indications B B C Patients With Nonspecific Chest Pain I I I I I I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
High-risk findings on noninvasive testing
Patients with recurrent hospitalizations for chest pain who have abnormal (but not high-risk) or equivocal findings on noninvasive testing
All other patients with nonspecific chest pain B B C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

5. Indications
Patients With Unstable Acute Coronary Syndromes (Class I and III only) I I I I I I I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures)
An early invasive strategy is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events
An early invasive strategy is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization
An early invasive strategy is not recommended in patients with acute chest pain and a low likelihood of ACS
An early invasive strategy should not be performed in patients who will not consent to revascularization regardless of the findings B A C C C
Source: Anderson JL et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1–157

6. Indications A A B C C Patients With STEMI (Class I and III only) I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
Diagnostic coronary angiography should be performed:
In candidates for primary or rescue PCI
In patients with cardiogenic shock who are candidates for revascularization
In candidates for surgical repair of ventricular septal rupture (VSR) or severe MR
In patients with persistent hemodynamic and/or electrical instability
Coronary angiography should not be performed in patients with extensive comorbidities in whom the risks of revascularization are likely to outweigh the benefits A A B C C
Source: Antman EM et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Available at

7. Indications
Patients With Post-revascularization Ischemia (Class I and III only) I I I I I I I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
Suspected abrupt closure or subacute stent thrombosis after percutaneous revascularization.
Recurrent angina or high-risk criteria on noninvasive evaluation within 9 months of percutaneous revascularization
Symptoms in a post bypass patient who is not a candidate for repeat revascularization
Routine angiography in asymptomatic patients after percutaneous transluminal coronary angioplasty (PTCA) or other surgery, unless as part of an approved research protocol B C C C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

8. Indications C C C C B C B C C
Perioperative Evaluation Before (or After) Noncardiac Surgery (Class I and III only) I I I I I I I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
Evidence for high risk of adverse outcome based on noninvasive test results
Angina unresponsive to adequate medical therapy
Unstable angina, particularly when facing intermediate or high-risk noncardiac surgery
Equivocal noninvasive test result in a high-clinical- risk in patients
Low-risk noncardiac surgery, with known CAD and no high-risk results on noninvasive testing
Asymptomatic after coronary revascularization with excellent exercise capacity (>7 METs)
Mild stable angina with good left ventricular function and no high-risk noninvasive test results
Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (eg, LVEF <0.20), or refusal to consider revascularization.
Candidate for liver, lung, or renal transplant >40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome C C C C B C B C C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

9. Indications
Patients With Valvular Heart Disease (Class I and III only) I I I I I I I I I
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
Before valve surgery or balloon valvotomy in an adult with chest discomfort, ischemia by noninvasive imaging, or both
Before valve surgery in an adult free of chest pain but of substantial age and/or with multiple risk factors for coronary disease
Infective endocarditis with evidence of coronary embolization
Before cardiac surgery for infective endocarditis when there are no risk factors for coronary disease and no evidence of coronary embolization
In asymptomatic patients when cardiac surgery is not being considered
Before cardiac surgery when preoperative hemodynamic assessment by catheterization is unnecessary, and there is neither preexisting evidence of coronary disease nor risk factors for CAD B C C C C C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

10. Indications
Patients With Congenital Heart Disease (Class I and III only) I I I I I I
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
III
III
III
III
Before surgical correction of congenital heart disease when chest discomfort or noninvasive evidence is suggestive of associated CAD
Before surgical correction of suspected congenital coronary anomalies such as congenital coronary artery stenosis, coronary arteriovenous fistula, and anomalous origin of left coronary artery
Forms of congenital heart disease frequently associated with coronary artery anomalies that may complicate surgical management
Unexplained cardiac arrest in a young patient
In the routine evaluation of congenital heart disease in asymptomatic patients for whom heart surgery is not planned C C C B C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

11. Indications B C C C Patients With CHF (Class I and III only) I I I I I
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
III
III
III
III
CHF due to systolic dysfunction with angina or with regional wall motion abnormalities and/or scintigraphic evidence of reversible myocardial ischemia when revascularization is being considered
Before cardiac transplantation
CHF secondary to postinfarction ventricular aneurysm or other mechanical complications of MI.
CHF with previous coronary angiograms showing normal coronary arteries, with no new evidence to suggest ischemic heart disease B C C C
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;

12. Contraindications
There are no absolute contraindications to cardiac catheterization
Relative contraindications include:
Coagulopathy (Radial approach can be attempted based on urgency)
Decompensated congestive heart failure
Uncontrolled hypertension
Pregnancy
Inability for patient cooperation
Active infection
Renal failure
Contrast medium allergy

13. Equipment & Technique
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 or 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

14. 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

15. 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

16. Complications
The overall risk of major complications with coronary angiography is 1-2%. This includes death, myocardial infarction, stroke, bleeding, vascular complications and contrast reaction.

17. Catheter Selection
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 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

18. Flow Rate and Volume
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
Source: Baim, DS et al. Grossman’s Cardiac catheterization, angiography and intervention. Lippincott Williams & Wilkins, Philadephia

19. Standard Angiographic Views
Left Coronary Artery
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

20. Standard Angiographic Views
Left Coronary Artery (other 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

21. Standard Angiographic Views
Right Coronary Artery
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

22. 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
Spine to the RIGHT
LAO view
Cranial view
Catheter and spine to the LEFT
Catheter at the CENTER
PA view
Diaphragm shadow
RAO view
Caudal view
Caudal view
No diaphragm shadow
No diaphragm shadow

23. Standard Angiographic Views
Left Coronary Artery
LAD
LAD LM
Diagonal
LCx
Septals
Distal LAD
Distal LAD fills by collaterals
RAO 20 Caudal 20
RAO 20 Caudal 20
Best for visualization of LM bifurcation and proximal LAD and LCx
Knowledge 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

24. Standard Angiographic Views
Left Coronary Artery LM
LCx
LCx LM
LAD
LAD
Diagonal
Septals
Diagonal
Septals
Distal LAD
Distal LAD
LAO 50 Cranial 30
PA 0 Cranial 30
Best for visualization of proximal and mid LAD and splaying of the septals from the diagonals. Also ideal for visualization of distal LCx
Best for visualization of LM proximal and mid LAD

25. Standard Angiographic Views
Left Coronary Artery
Diagonal
LAD
LAD
Diagonal LM LM OM
LCx
LCx
Septals
Distal LAD
Distal LAD OM
LAO 50 Caudal 30
PA0 Caudal 30
‘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

26. Standard Angiographic Views
Right Coronary Artery
Proximal RCA
Proximal RCA
Mid RCA
Distal RCA
PDA
Mid RCA
Mid RCA
PDA
Distal RCA
PDA/PLV
LAO 30
RAO 30
PA 0 Cranial 30
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

27. 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
Grading TIMI myocardial perfusion blush grade
Identifying and quantifying coronary collaterals

28. 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 ;12:528-45

29. 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

30. Gibson CM, et al. Am Heart J. 1999;137:1179–1184
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

31. 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:

32. Image courtesy Dr. Frederick Feit
Coronary Aneursym
Coronary Aneurysm: Vessel diameter > 1.5x neighboring segment
Incidence: 0.15%-4.9%; very rare in LMCA
Etiology: mainly atherosclerosis; other causes include Kawasaki’s, PCI, inflammatory disease, trauma, connective tissue disease
Treatments: include observation, surgery, occlusive coiling, covered stents, therapeutic coiling
Image courtesy Dr. Frederick Feit

33. Coronary Anomalies Prognosis benign Prognosis benignLM
LAD
RCA
Anomalous LCx from right cusp
Anomalous RCA from left cusp
Image courtesy Dr. Frederick Feit
Image courtesy Dr. Frederick Feit
Prognosis benign
Prognosis benign
Left coronary artery arising from the right sinus of Valsalva - course relative to great vessels must be defined as interarterial course portends an increased risk of sudden death

34. Coronary Anomalies Increased risk of sudden death Prognosis benign
LCX
LCX
LAD
AORTA
AORTA
LAD
PULMONARY ARTERY
PULMONARY ARTERY LM LM
RCA
RCA
Anomalous LCA from right sinus - Inter-arterial Course
Anomalous LCA from right sinus - Retro-aortic course
Increased risk of sudden death
Prognosis benign