Coronary angiography standard views

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Coronary Angiography

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General Principles

Overview
Historical Perspective
Contraindications
Appropriate Use Criteria for Revascularization
Complications
Technique
Film Quality

Anatomy & Projection Angles

Normal Anatomy

Coronary arteries
Dominance
Right System
Left System
Left Main
Left Anterior Descending
Circumflex
Median Ramus

Anatomic Variants

Separate Ostia
Anomalous Origins
Fistula

Projection Angles

Standard Views
Left Coronary Artery
Right Coronary Artery

Epicardial Flow & Myocardial Perfusion

Epicardial Flow

TIMI Frame Count
TIMI Flow Grade
TIMI Grade 0 Flow
TIMI Grade 1 Flow
TIMI Grade 2 Flow
TIMI Grade 3 Flow
TIMI Grade 4 Flow
Pulsatile Flow
Deceleration

Myocardial Perfusion

TIMI Myocardial Perfusion Grade
TMP Grade 0
TMP Grade 0.5
TMP Grade 1
TMP Grade 2
TMP Grade 3

Lesion Complexity

ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis

Preprocedural Lesion Morphology

Eccentricity
Irregularity
Ulceration
Intimal Flap
Aneurysm
Sawtooth Pattern
Length
Ostial location
Angulation
Proximal tortuosity
Degenerated SVG
Calcification
Total occlusion
Coronary Artery Thrombus
TIMI Thrombus Grade
TIMI Thrombus Grade 0
TIMI Thrombus Grade 1
TIMI Thrombus Grade 2
TIMI Thrombus Grade 3
TIMI Thrombus Grade 4
TIMI Thrombus Grade 5
TIMI Thrombus Grade 6

Lesion Morphology

Quantitative Coronary Angiography
Definitions of Preprocedural Lesion Morphology
Irregular Lesion
Disease Extent
Arterial Foreshortening
Infarct Related Artery
Restenosis
Degenerated SVG
Collaterals
Aneurysm
Bifurcation
Trifurcation
Ulceration

Left ventriculography

Technique
Quantification of LV Function
Quantification of Mitral Regurgitation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Standard Angiographic Views

Rotation describes the position of the image intensifier around the longitudinal axis of the patient. LAO refers to rotating the camera to the patient's left (catheter and spine will be on the right side of the image), RAO to the patient's right (catheter and spine on the left side of the image). Angulation describes the position of the image intensifier in the short axis of the patient. Camera can pivit toward (cranial) or away (caudal) from the patient's head. Diagram

For the beginner angiographer the anatomic landmarks formed by the spine, catheter and diaphragm provide information to discern which tomographic view from which the image is obtained. In the LAO view (figure 1) the catheter and spine are seen on the right side of the image, while in the RAO (figure 2) they are found on the left. PA imaging (figure 3) places these landmarks in the center of the image. Cranial angulation can usually be distinguished from caudal angulation by the presence of the diaphragm. For cranial imaging, the patient should be asked to inspire to remove the diaphragmatic shadow from the image.

Post-surgical Views

  • Left Lateral; LIMA (body)
  • Right Cranial; LIMA to mid LAD
  • Right Caudal; LIMA to distal LAD
  • Left Lateral; LIMA to distal LAD
  • Right Cranial; LIMA to diagonal arteries
  • Left Lateral SVG to LAD
Figure 1
Figure 2
Figure 3

Left Coronary Artery

The left main coronary artery gives rise to the left anterior descending artery and the left circumflex coronary artery. Complete visualization of these arteries and their branches requires care and rigor to ensure complete anatomical documentation. Often bifurcations and vessel foreshortening and overlap cause errors in stenosis estimation. There are no steadfast rules in which tomographic views are most useful. Generally, for circumflex and proximal epicardial visualization the caudal views are most useful. For LAD and LAD/diagonal bifurcation visualization the cranial views are most useful. Overall, if there is not a significant limitation on contrast utilization, standard 'around the world' angiography using a selection of the following angiographic views will document left coronary anatomy.

RAO 20 - Caudal 20

RAO Caudal

RAO Cranial

AP 0 - Caudal 30

PA Caudal

LAO 50 - Caudal 30

LAO Caudal

LAO 50 - Cranial 30

LAO Cranial

AP 0 - Cranial 40

PA Cranial

Right Coronary Artery

LAO View

Initial angiographic imaging of the RCA in this view (LAO 30) gives the best view of significant ostial and proximal RCA disease.

RAO View

The mid RCA is best visualized in the straight RAO 30 position.

AP 0 Cranial 30 View

The bifurcation of the distal RCA and rPDA is best seen in the AP 0 Cranial 30 view with a small breath in.

References


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