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CLINICAL PROGRESS
Anatomy of the Coronary Circulation
Living Man
in
Coronary Venography
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By GOFFREDO G. GENSINI, M.D., SALVATORE Di GIORGI, M.D.,
OSMAN COSKUN, M.D., ADORACION PALACGO, M.D.,
AND ANN E. KELLY, B. S.
A number of different tubings and catheters
were extensively tested on experimental animals
(dogs). Two different generations of catheters
were found satisfactory for human coronary visualization and they are now commercially produced by the United States Catheter and Instrument Corporation, according to our specification.
The coronary venous catheter no. 1 is a modified
Dotter-Lukas instrument having a much smaller
balloon than the parent model (10 mm. long)
located 6 mm. from the tip. The catheter is made
of woven Dacron and is available in size 8Y2 F.
The coronary venous catheter no. 2* is a 7F woven Dacron which tapers down to size 532 F toward the tip. The very tip is shaped like an olive,
having a size of 9F (fig. 1).
For coronary venography one of the special
catheters described is introduced into the left
basilic vein, surgically exposed under local anesthesia. The catheter, slightly curved at its tip, is
guided to the right atrium and then the patient
is placed in a right anterior oblique position. The
tip of the catheter is then directed caudally toward the entrance of the inferior vena cava and
posteriorly to the tricuspid valve, so that it will
point away from the operator and directly toward
the entrance of the coronary sinus. A slight forward motion usually places the tip of the catheter
in the coronary sinus and the great card:ac vein,
which are running along the posterior atrioventricular groove, crossing the heart shadow in a
diagonal direction, roughly going from 7 to 1
o'clock. The balloon of the specially modified
balloon catheter (no. 1), must be placed in the
great cardiac vein, well past the orifice of the
posterior interventricular vein, in order to leave
the drainage of the latter unhampered. The small
IN CONTRAST to the continuing interest in
coronary arteriography, the in vivo angiographic study of the human coronary veins
(coronary venography), has been largely
neglected. Tori' was the first to outline some
of the larger veins by retrograde injection of
contrast material into the catheterized coronary sinus. Occasional or accidental opacification of this structure has been reported by a
few authors.2 3 Recently Gensini et al. introduced the technic of occlusion coronary venography4 5 for the study of myocardial toxicity of contrast materials6 and as a means of
exploring the feasibility of retrograde emergency closed-chest perfusion of the ischemic
myocardium.7
This is a description of this previously unreported technic and of the results obtained
in a series of clinical cases.
Materials and Methods
Most of the patients included in this study
represented a selected group of cases, usually
older children or young adults with normal cardiovascular systems in whom cardiac catheterization
had been performed to rule out congenital heart
disease. A few of the older patients were being
investigated to assess the extent and operability
of their rheumatic valvular involvement.
From the Monsignor Toomey Cardiopulmonary
Laboratory and Research Department, St. Joseph's
Hospital, Syracuse, New York.
Supported by research grants from the American
Heart Association and The John Hartford Foundation.
*Developed by Dr. Salvatore Di Giorgi.
778
Circulation, Volume XXXI, May 1965
CORONARY VENOG NAAP7IY
779
The tapereedthieter xxvitlh the olive tip (no.
2), shotuld be ptished well toward the periphery.
It is ismiallx xvedlged in the initial portion of the
ait-itenior interventricuilar veinl. Occasioniially, the
catheter imiay be xvedged into the posterior initervenitriicuilar vein.
The conitiast agenit sldoti l)e inijected while its
progression is wxxatclhedI oni the image initenisifier
andi(I filmeiid wxith the cineccamera. The amounLt tsed
.1 I y F I I
-1
21
i
1 -,.-L
T I t I I I I I I I I I I i 1 4
I I j I g I I i I T it I I 't I
m
for anvy one ii-ijectioni slhoul(l be su-ifficienlt to outline all the m]ajor veinis aiind their branches.
Doses of firomi 5 to 15 ml. of contrast agent, mannazlly inijected, are usu.ally suifflcienit to ouitline the
corouiiary venotis systemii of the adcluLlt. The lower
(dose (6 nl-.) is iusLually satisfactory for in-jections
iln the vedged positioni, wlbile the higher ones
mnav he niecessarvy vhleni the balloon catheter- is
uisedl. Smialler closes are requiriiied in. children. The
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g(en1tle grdoal injcctio)i of coiitrast m-iater-ial ini
atni occhided Itaio/or vcioiis ch anniiel is wvell toler-
Illl~~~~~~
IT::II.TI'::I II II-I--I II Il I llllllMi
Figure 1
A, tolp. Spccially mtodlified ballooo Catlecter (no. 1) ftl
o'cclsiioi corouatay vciograplhy. 13, bottom. 71/ic tip) of
caltIet('i' 110. 2 for' coonarij venoits ttedpcd techn11ic.
balloon cani then be iniflaited vith 2 to 4 ml. of
puri-e carbon. (lioxi(le xvhile the presstire fromll the
catheter tip is recoirded. Saitisfactory iniflationi of
the balloon is obtained as sooni a1s the recorded
pressure shovs the evidence of complete venouis
occlusioni, whichl is demilonstrated Iby a chlaracteristic shift from the atrial wavefoirmi of thie unocecluded corollary sinulls to the ventrictilar-looking c'oi1}plexes of the occluded coronarv xvenoos pressur(-e(fig. 2) Bletween pressur e determinations, the
balloon slihouldl he (leflated, xx ith the catheter left
in. place.
attecl bx' the patienit. No appreciable electr-ocardiogriaphic changes x iTre oticed as lonig ats 110
eAcessixve pressture xvas applied(i'
Contrast agenits 1uise(l in this series of piatienits
wvere either Renogllfiaim 76, (alriihografin (Squiibb)
or the uiew 80 pei cent megluimine iothalamnate
\lallinckrodt). All of these contrast agents had
beeni founid to be free froma significanit m-avocardial
toxic eflects, eveni xxhen injected in con-sidler-ablv
Iarger aimouinits inlto the occluded or xvedlgedI coromiarx veinis of dogsInijections xx\ere recorledl with a 35-mmiiii. ciniecamera attached to a Picker- 8-inich image intensifier. The film uise(d w as Kodak Double X,
(leveloped in a Fisher P ocess-sall xvith Pix Developer at 83° C., at at speed of 4 feet per minullte.
In a few cases the Sehit auder Seriograph was
nscd xxitlh Kodak Royal bluie filims. After the
inovxies wvere viewcd oii ai Tage-Arnioe 35-mm.
e(litor-, selecte(d fr-amiies xx cie e 1lulzo'ged aind priinted
xvitlh conventional miietl odls. Electrocardiograms
and pressures weme iecorded xwith a 4-clhaninel
150 Sanborn alid Statham strai i-gauig.es.
-
Results
v60>
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The Coronary Venous System of the
Normal Human Heart
The uniiderstandinig (If the coroniary veno0f-
gr-am obtained xvith the opacification of the
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cor-oniary venouis systemii requires a brief rexviexx of the normal aniatomny of these vessels,
in the commonily uised radiographic projections (aniteroposterior, lateral, right and left
olliques) (fig. 3a-d).
One (f the m-ost strik-ing featuires of the
coronary ven otis systemn is the abundance of
large anastom(oses lbetwveen all najor veinis.
GENSINI ET AL.
780
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C
Figure 3
Roentgenographic projectiotns of thie human coronary ven1ous system-a, antero/)osterior viewt;
b, left anterior oblique; c, righ7t aniterior oblique; d, left loteral. The vessels in black are aniteriorly located; the ones in gray, posteriorly.
This situation makes possible the visualization of the entire venous return to the coronary sinus when contrast material is injected
through a catheter wedged into one of its
large l)ranches (fig. 4). With the balloon
catheter anid graded pressure injection in the
occluded great cardiac vein, even the anterior
cardiac veins can be visualized (fig. 5).
The coronary veins are probably subject to
as many, or perhaps even more, individual
variations than the human coronary arteries;
however, their basic architecture is quite simCirculti,at, Volunie XXXI, May 1965
CORONARY VENOGRAPHY
"i81
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Figure 4
Anter,oposterior vieic of the hear-t during coronta:
venograj)hy with catheter wvecdged in anrtfcwior in-tet.entri alar vein in a 10-ylear-old boyl.
ple and cani be r-cadily appreciated in b)oth the
wxcll
the righlt anterioraniteroposterior
oblique view (figs. 4 and 6).
as
as
Diagrammatically, this system cani be repby two large triangles havina their
resented
apexes
on
either side of the
Figure
ape.x of the heart,
5
Lateral vievw of the heart du/ring occlision
venography in a 28-year-old
man.
Circulation, Volume XXYI. Malf,y 796t5
coronaryl
Figure 6
Riight aniter ior obliquze view of the heart showvingtlil
opacification of ma/or coro nary vein in a 10-year-oldI
b)o!,.
anid lainged at their bases on the great cardiac
veinl and the coroniary sinus. The sides of the
first trianigle, the larger and the onie more
medially located, are formed by the anterior
and posterior intervenitricuilar veinis. The sides
of the second triangle, the smaller aind the one
located on the free xvall of the left venitricle,
are formed by thle left diagonal veinis anid
obtuse marginial veins. The hiniges ruinininig
along the posterior atrioventricular groove are
the great cardiac veini anid the coronary sintis.
A tail-like appendage, the small cardiac veinl,
lies beloxv this set of triangles and joins the
lower hinge, i.e., the coronary sinuis at its
ostiuim. This system, xvhiclh empties in the
right atriuim throuigh the coroaiary sitnus, is by
far the most important venlouIs nietNvork of the
human heart, draining practically all the
1)lod( of the initerventricular septum, the left
venitricular wvall anid adjoining areas, and part
of the right ventricle, or approximately 85
per cent of the coronary blood flow.
The remaining 15 per cent of the venous
retturn is drained by channels ouitside this
framework of hinged triangles. These vessels
are the anterior cardiac veins anid the elusive
thebesian channels.
The anterior cardiac veins can easily be
opacified. Figure 5 shows the rich network of
782
8GENSINI ET AL.
Figure 7
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Anteroposterior vienv. Opacification of poste ior inlterventricnlar vent (pi), posterior scptal
bi$anchCes (s),
andl. smrlall car(liae. rein (sc) (rig/it mnarginlal veiti) in a
30-yiear-old woitan.
vessels joining the- aniterior interventricutlar
veinl (a vein of the coroniary sinus systemn)
xvith the anterior cardliac vein, encircling
the outfioxx tract of the right ventricle and
the pulmonary valve. The long and slender
vesse-tl, toxvard the riglht uipper margin of the
photograph, is the venous rinig acconmpaniying
Vieussenis' larterial rinig arouniid the root of
the puilmonary artery. While oni the left side
it issues from the anterior interventricuilar
vein, on the other side it appears to open be-
nieath the right atrial appendage anid at the
juniiction letveen the siipe-ior ven1a cava anid
the riglht atriurm. The small cardiac vein (or
riight marginal vein ) described in ouir dia(rrammatie representation as the tail-like aippenlaear at the bottom of' the hinge, runii.s
along the acutecmargin of the heart anid occasionially may empty into the right atriuimiwxith ani orifice separate from that of the
coronary sinius. As shoxwn in figuire 7, a selective opacificationi of the posterior initerventricuilar vein (also knovwn as the mi(icdle cardiac
xcim ) often n ot onlv demonstrates the posterioi- septal l)ranches of this vessel, l)ut also
its anastomosis wvith tlhec riglht marginal vein,
Nx hIiclh thenl) becomes -xwell visualized in its
cilire Course.
The thebesian chlannIIels are imich more
(lifficuilt to demoinstrate, as they are extremnely
small anid short vessels, opening tlhrou(ghl individutal ostia into the cavities of the heart.
We we re al)le, lhowever, to dlenmonistrate these
channels ill a 58-year-old woman xwho xvas
fouind to have an at-trial scptal defect and a1
left suiperior venati eava entering the coronary
sinuiis. In this patient tlhe smn-all car-diac veini
(or righit marginial. veii ) coild be selectively
catheterized. The iInjectioni of this vessel
throighi the wve(cged cathieter demnonistrated,
figu-rec 8, ratlher thani the uisual veniouis arborization, a sponge-like netwx ork located on the
Figure 8
Lateral viewe. Catheteri twcldged in srt/I(ll cardiac veitn. Thrce suecessive frtames fronti 35-oittz.
nmotie s/towing the finte sponge-likc arbortizatiolns of thze tIlhe.siatt veins, and the (dispetsion of
thc co(ntrast agenit in thc right vcntrienlar cavityl in a 5S-y (lr-oldl wt.ivo11l.
(Circ iaTlon
lIn/'e \-XXI, Almv 196-5
CORONARY VENOGRAPIJY
1'7c. 3
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Figure' 10
A\nthropostcrior victw. Opjwifieation of the inlitial porlioni of thef corotiaril sinis slioiuicii the tbhebsiaii
air i)
( 110)5-
Cardinal
\
(cin. Thlis x essel r1un).s, ias its namel1
ind(licates, dia(lonally ohi thle posterior surface
of thie left atrium, (lireetecd inelially and
caudally. 11w grcat cardliac Vein becomes the
C(orlarV Silltis at the point NN1here the vein of
Niarshall (TIrainis iInto it. This spot is occasionlall'nmarked b1w a smiall indentation Produced
1v the \'enous valve of Vieiissens (fi. 9a
Fi-ure
11(Co .srzcce.ssicc Ieft anterior obliqne ictars of the
coroiiaryj sin1is ardildthureat cardiac rei1ci, shownipi
the vala/r of ierisseis (arrows).
wvall
of
(drainagc
the
of
righlt
the
ventricular cav\ity
witlh
mat('rial
en-itricle,
conItrast
l)y
multiple
inito
th
way of separate shiort
\\
The smiall fold of tissuie at the ostitiumi of the
coronary silt is, know%\,n as the thel)esian valve,
shouild 1w)c imentioned, as it imiay occasionally
offer a temporary ol)stacle to the catlheterizationi of the coroniary sinutis. Occasionially it may
l,e reeorrnized in the anteroposterior view (fig.
10), following opacification of the siniuis, as a
smaill ridge locatedl at timeihottom of the openiing he,,tween ftlhe coronary siniuts anId thlie r-ighlt
chianniels.
Occasioially, the in(lividuial openiings of
thebl)esian veins iinay 1)e demonstrated at
times of riglht or left ventricilari conitrast inathe,
terial inijectioII when thec catheter accidentally
micay wedge itself into (1ne of them. InI this
situatioinI, howcver, diffuse inifiltrationi of a
large area of thew myyocar-dinii-n Imay enscus,
a
oftemi
oi)scuriiig
the individual
sall
i
le(ft atrial
vessels.
vein of great anatomic
significainee is the ohlique vein of Marshiall,
the residutial of thic emi)bry ic left suiperior
Chirulation, Volume XX\\,!. Miay 196S
Suiiiniiiary ami(i Coiiclusions
The r-adiorgraphlice anaitomtiy of the coronaryiv
x eimis of the heart has i)een investigated in
thile conlsciolus lihiuan i)being with ouir original
inethod of occluisioni cor-oniary veoTgraphiv
anid high-speced cinefluorography.
This method, properly applied, with uise, of
the equipmient and the procedures descrihed,
is a safe an,d a simple one, affordinig thle visualization of a vascular (listr-ict of the io(ly
which ( 1 ) hladl not i)een previously investi-
784A
GENSINI ET AL.
gated with modern angiographic technics and
(2) has recently acquired greater importance
after the growing interest in the roentgenographic and hemodynamic studies of the coronary circulation, especially those involving
coronary blood flow recording via coronary
sinuis catheterization.
References
1. ToRi, G.: Radiological visualization of the coronary sinus and coronary veins. Acta radiol.
36: 405, 1952.
2. AGUZzi, A., Di GUGLIELMO, L., BALDRIGHI, V.,
AND MARLEY, A.: Visualizazione del circolo
venoso coronarico durante cardioangiografia.
Radiol. med. 40: 140, 1954.
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
3. CAMPETI, F., GRAMIAK, R., WATSON, J. S., RAMSEY, G. H., AND WEINBERG, S.: Visualization
of the coronary sinus in cineangiocardiography. Circulation 12: 199, 1955.
4. GENSINI, G. G., Di GIORGI, S., MURAD-NETTO,
S., DELMONICO, J. E., JR., AND BLACK, A.:
The coronary circulation: An experimental
and clinical study. Read before the 4th World
Congress of Cardiology, Mexico City, October,
1962. Memorias del IV Congreso Mundial de
Cardiologia, Vol. I A, pp. 325-342. Mexico
D. F., July, 1963.
5. GENSINI, G. G., Di GIORGI, S., AND MURAD-NETTO, S.: Coronary venous occluded pressure.
Arch. Surg. 86: 72, 1963.
6. GENSINI, G. G., AND Di GIORGI, S.: Myocardial
toxicity of contrast agents used in angiography.
Radiology 82: 24, 1964.
7. GENSINI, G. G., Di GIORGI, S., MURAD-NETTO,
S., AND DELMONICO, J. E., JR.: Percutaneous
retrograde venous perfusion of the myocardium. Am. J. Cardiol. 9: 818, 1962.
Ultimate Purpose
Our present era is characterized by something new in the life of man, and that is the
impact of science and applied science or technology on our lives. However, our ultimate
goal is not science, just for science's sake; our goal is a higher degree of culture and
civilization. We should realize that science is not the measure of civilization-science and
technology are merely tools, not ends in themselves.-GASToN F. Du Bois.
Circulation, Volume XXXI, May 1965
Anatomy of the Coronary Circulation in Living Man: Coronary Venography
GOFFREDO G. GENSINI, SALVATORE DI GIORGI, OSMAN COSKUN,
ADORACION PALACIO and ANN E. KELLY
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Circulation. 1965;31:778-784
doi: 10.1161/01.CIR.31.5.778
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1965 American Heart Association, Inc. All rights reserved.
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