DECISIONS REGARDING ANGIOPLASTY vs BYPASS SURGERY vs MEDICAL PowerPoint Presentation

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Coronary Anatomy, Variants and Lesion Characteristics George W. Vetrovec, M.D. Medical College of Virginia Campus Virginia Commonwealth University January 2003

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Coronary Angiography Optimal Coronary Angiography Goal is to adequately opacify coronary artery without streaming Properly positioned catheter Sufficiently large catheter lumen for necessary and available contrast injection Always insure “reflux”

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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Routine Angiographic Views Left Coronary Shallow RAO, AP Caudal LAO Caudal LAO Cranial RAO Cranial Right Coronary LAO Cranial AP Cranial, Shallow RAO LAO Caudal

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Optimal Coronary Angiographic Views: Left Main Segment Routine Adjunctive Ostial LAO Caudal AP Caudal Body RAO Caudal AP Caudal RAO Cranial Distal LAO Caudal LAO Cranial RAO Caudal

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Left Main: LAO Caudal

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Optimal Coronary Angiographic Views: Left Anterior Descending Segment Routine Adjunctive Ostial LAO Caudal AP/RAO Caudal Body RAO Caudal AP Cranial LAO&RAO Cranial Distal RAO LAO Cranial RAO Caudal

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LAD: RAO Cranial

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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AP Cranial: Distal Stent Dissection

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LAD–Diag Lesions in the AP Cranial View

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AP Cranial: Distal Stent Dissection

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Optimal Coronary Angiographic Views: Circumflex Segment Routine Adjunctive Ostial LAO Caudal AP Caudal Body Shallow RAO AP Caudal LAO LAO cranial Distal Shallow LAO LAO Cranial Shallow RAO AP caudal

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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Proximal Ramus Stenosis

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Optimal Coronary Angiographic Views: Right Coronary Artery Segment Routine Adjunctive Ostial/Prox LAO Cranial Lateral(90-110) AP Caudal Mid Vessel Shallow RAO Lateral LAO Caudal Distal Bifurcation LAO Cranial AP Cranial PDA Shallow RAO AP Cranial PLB AP caudal Lateral Cranial

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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Optimal Coronary Angiographic Views: Vein Bypass Grafts Segment Routine Adjunctive Ostial LAD Shallow RAO AP Caudal RCA LAO LAO Caudal Body RAO LAO

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Optimal Coronary Angiographic Views: Bypass Graft Insertion Site SEGMENT ROUTINE* ADJUNCTIVE LAD/Diag AP Cranial Lateral Circ LAO AP Caudal RAO Cranial RCA LAO Caudal Lateral RAO Caudal PDA/PLB(Bif) AP Cranial Lateral PDA/PLB (Mid) LAO Cranial RAO Caudal *Similar Views for same area of native vessel

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Optimal Coronary Angiographic Views: Internal Mammary Graft SEGMENT ROUTINE ADJUNCTIVE Ostial Shallow RAO LAO Cranial Mid Vessel Shallow RAO Lateral Insertion to: LAD RAO Cranial Lateral (+/-) RCA LAO Lateral RAO Left Subclavian AP RAO Cranial

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Coronary Angiography Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System Type A Discrete Concentric Readily accessible Smooth Contour Little or no calcification Non ostial No major side branch involved Absence of thrombus

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Coronary Angiography Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System Type B Tubular Eccentric Moderate tortuosity Moderately angulated (45 – 900) Irregular contour Moderate – heavy calcification Total occlusion (< 3 months) Ostial Bifurcation lesion Thrombus present Note: B1 = characteristic only; B2 = 2 or more characteristics

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Coronary Angiography Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System Type C Diffuse Excessive Tortuosity Extremely angulated Total occlusion (> 3 months) Inability to protect major side branch Degenerated vein graft

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Coronary Angiography Distal Blood Flow/Collateral Classification Based on TIMI Trial TIMI Grade Contrast Flow 0 (No perfusion) Antegrade flow to lesion; no flow beyond occlusion 1 (Penetration with Contrast passes beyond minimal perfusion) lesion but does not opacify distal vessel during cine run 2 (Partial perfusion) Contrast passes obstruction and fills distal vessel.However, rate of filling and/or washout slower than vessel segments outside lesion 3 (Complete perfusion) Contrast passes freely into distal at same visual rate as unaffected adjacent vessels

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Coronary Angiography Distal Blood Flow/Collateral Classification Based on TIMI Trial Collateral Supply Contrast Flow 1 Absent 2 Minimal 3 Well developed Adapted from TIMI

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Coronary Angiography NHLBI Classification System for Coronary Dissection Dissection A Small radiolucent area within the lumen of the vessel B Linear, nonpersisting extravasation of contrast C Extraluminal, persisting extravasation of contrast D Spiral-shaped filling defect E Persistent lumen defect with delayed anterograde flow F Filling defect accompanied by total coronary occlusion Length (in mm) Measure end to end for type B through F dissections Staining Persistence of contrast within the dissection after washout of contrast from the remaining portion of the vessel

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Coronary Angiography Coronary Anomalies Common: Insignificant Conus Separate Ostium from RCA 50% Left Circ from RCA 0.3% Uncommon: Clinically Significant LM from Proximal RCA Courses between Great Vessels Associated with sudden Death

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Coronary Angiography Left Circumflex from RCA

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Coronary Angiography Left Main Arising from RCA

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Coronary Angiography Left Main from RCA Angulation at origin of LM Compression of LM

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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Coronary Angiography Adapted from Seroth et al. Am J Cardiol 1990;65:891-898 LM-Right Sinus of Valsalva Septal Course

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Coronary Angiography Adapted from Seroth et al. Am J Cardiol 1990;65:891-898 LM-Right Sinus of Valsalva Retroaortic Course

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Coronary Angiography Adapted from Seroth et al. Am J Cardiol 1990;65:891-898 LM-Right Sinus of Valsalva Anterior Free Wall

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Coronary Angiography LM-Right Sinus of Valsalva Interarterial Course Adapted from Seroth et al. Am J Cardiol 1990;65:891-898

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Anomalous LM: Interarterial Course

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Anomalous LM: Interarterial Course

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Anomalous LM: Interarterial Course

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.

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Coronary Angiography Pepine et al. Diagnostic and Therapeutic Cardiac Catheterization, 3rd Ed.