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CARDIAC ANGIOGRAPHY Rajesh A. Shah M.D. Orlando Cardiac & Vascular Specialists ACS Director, Florida Hospital System No Disclosures OBJECTIVES 1. Introduction to the Cardiac Catheterization Lab 2. Access Site 3. Angiographic Anatomy 4. Coronary Anomalies 5. Vascular Complications 6. Coronary Angioplasty – Stent vs CABG 7. Cardiogenic Shock Support Welcome to the Cath Lab GROIN ANATOMY Inferior Epigastric Artery Role of fluoroscopic identification of landmarks and/or ultrasound Femoral Artery Landmarks: Inguinal ligament- anterior superior iliac spine to pubic tubercle FA crosses inguinal ligament approximately 1/3 from medial aspect of ligament Profunda Femoris Artery Superficial Femoral Artery Radial Access Curve and Tip length Tip Orientation Lateral Wall support 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 LAO view Cranial view RAO view Caudal view Catheter and spine to the LEFT No diaphragm shadow Catheter at the CENTER PA view Spine to the RIGHT Diaphragm shadow Caudal view No diaphragm shadow AHA Standard Angiographic Views Left Coronary Artery LAD LAD LM Diagonal LCx Septals Distal LAD Distal LAD fills by collaterals RAO 20 Caudal 20 Best for visualization of LM bifurcation and proximal LAD and LCx RAO 20 Caudal 20 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 Standard Angiographic Views Left Coronary Artery LM LCx LCx LM LAD Diagonal LAD Septals Diagonal Septals Distal LAD PA 0 Cranial 30 Best for visualization of LM proximal and mid LAD Distal LAD LAO 50 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 Standard Angiographic Views Left Coronary Artery LAD LAD Diagonal LM Diagonal LM OM LCx Septals LCx Distal LAD Distal LAD LAO 50 Caudal 30 OM AP 0 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 Standard Angiographic Views Right Coronary Artery Proximal RCA Proximal RCA Mid RCA Mid RCA Mid RCA Distal RCA PDA LAO 30 Best for visualization of ostial and proximal RCA Distal RCA PDA PDA/ PLV RAO 30 Best for visualization of mid RCA and PDA AP 0 Cranial 30 Best for visualization of distal RCA and its bifurcation LEFT VENTRICULOGRAPHY 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 CORONARY ANOMALIES LM LAD RCA Anomalous LCx from right cusp Prognosis benign Anomalous RCA from left cusp Prognosis benign Left coronary artery arising from the right sinus of Valsalva – and runs in between then great vessels “interarterial” course portends an increased risk of sudden death Images courtesy Dr. Frederick Feit Coronary Anomalies LCX LCX AORTA LM LAD PULMONARY ARTERY RCA Anomalous LCA from right sinus - Inter-arterial Course Increased risk of sudden death AORTA LAD PULMONARY ARTERY LM RCA Anomalous LCA from right sinus - Retro-aortic course Prognosis benign Vascular Complications Distal Embolization Dissection Hematoma Retroperitoneal Hemorrhage Pseudoaneurysm AV fistula formation Iliac Artery Dissection Occlusion of Arteriotomy Site Thigh Ecchymosis / Hematoma Retroperitoneal Hematoma Retroperitoneal Hematoma Psuedoanuersym AV Fistula Coronary Angioplasty Coronary Angioplasty Coronary Artery Material: Stainless steel Cobalt alloy metal 45 YO AWMI 3V CAD vs. 3V CAD Role for PCI in MV CAD CTO – Non Surgical Candidate Left Main + Ostial RCA Multivessel CAD – Collateralized LAD MV Disease – CABG? 45 year old Aortic Root Aneurysm Post Infarction VSD IMPELLA ECMO Thank You
