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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