coronary angiography

Copyright © 2011 American Heart Association.

Coronary Angiography

Sripal Bangalore, M.D., M.H.A.and

Deepak L. Bhatt, M.D., M.P.H., F.A.H.A


OverviewCoronary Angiography

Indications Contraindications / Caution Equipment Equipment & Technique Precautions Pressure monitoring

Zeroing and Referencing Guide catheter selection Flow rate and volume Standard angiographic views Angiogram- interpretation

ACC/AHA lesion classification Other definitions TIMI flow and perfusion grades

Congenital coronary anomalies

IndicationsKnown or suspected CAD (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII CCS class III and IV angina on medical treatment High-risk criteria on noninvasive testing regardless of anginal severity Patients who have been successfully resuscitated from sudden cardiac

death or have sustained (>30 seconds) monomorphic ventricular tachycardia or non-sustained (<30 seconds) polymorphic ventricular tachycardia

Angina in patients who are not candidates for coronary revascularization or in whom revascularization is not likely to improve quality or duration of life

As a screening test for CAD in asymptomatic patients After CABG or angioplasty when there is no evidence of ischemia on

noninvasive testing Coronary calcification on fluoroscopy, electron beam computed

tomography, or other screening tests without criteria listed above

Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

IndicationsPatients With Nonspecific Chest Pain

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

High-risk findings on noninvasive testing Patients with recurrent hospitalizations for chest pain who have

abnormal (but not high-risk) or equivocal findings on noninvasive testing

All other patients with nonspecific chest pain


IndicationsPatients With Unstable Acute Coronary Syndromes (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII An early invasive strategy (i.e., diagnostic angiography with intent to

perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures)

An early invasive strategy is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events

An early invasive strategy is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization

An early invasive strategy is not recommended in patients with acute chest pain and a low likelihood of ACS

An early invasive strategy should not be performed in patients who will not consent to revascularization regardless of the findings

Source: Anderson JL et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1–157

IndicationsPatients With STEMI (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII Diagnostic coronary angiography should be performed:

a. In candidates for primary or rescue PCI

b. In patients with cardiogenic shock who are candidates for revascularization

c. In candidates for surgical repair of ventricular septal rupture (VSR) or severe MR

d. In patients with persistent hemodynamic and/or electrical instability

Coronary angiography should not be performed in patients with extensive comorbidities in whom the risks of revascularization are likely to outweigh the benefits

Source: Antman EM et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2004. Available at www.acc.org/clinical/guidelines/stemi/index.pdf.

IndicationsPatients With Post-revascularization Ischemia (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII Suspected abrupt closure or subacute stent thrombosis after percutaneous

revascularization. Recurrent angina or high-risk criteria on noninvasive evaluation within 9

months of percutaneous revascularization Symptoms in a post bypass patient who is not a candidate for repeat

revascularization Routine angiography in asymptomatic patients after percutaneous

transluminal coronary angioplasty (PTCA) or other surgery, unless as part of an approved research protocol


IndicationsPerioperative Evaluation Before (or After) Noncardiac Surgery (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII Evidence for high risk of adverse outcome based on noninvasive test results Angina unresponsive to adequate medical therapy Unstable angina, particularly when facing intermediate or high-risk

noncardiac surgery Equivocal noninvasive test result in a high-clinical- risk in patients Low-risk noncardiac surgery, with known CAD and no high-risk results on

noninvasive testing Asymptomatic after coronary revascularization with excellent exercise capacity

(>7 METs) Mild stable angina with good left ventricular function and no high-risk

noninvasive test results Noncandidate for coronary revascularization owing to concomitant medical

illness, severe left ventricular dysfunction (eg, LVEF <0.20), or refusal to consider revascularization.

Candidate for liver, lung, or renal transplant >40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome


IndicationsPatients With Valvular Heart Disease (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Before valve surgery or balloon valvotomy in an adult with chest discomfort, ischemia by noninvasive imaging, or both

Before valve surgery in an adult free of chest pain but of substantial age and/or with multiple risk factors for coronary disease

Infective endocarditis with evidence of coronary embolization

Before cardiac surgery for infective endocarditis when there are no risk factors for coronary disease and no evidence of coronary embolization

In asymptomatic patients when cardiac surgery is not being considered

Before cardiac surgery when preoperative hemodynamic assessment by catheterization is unnecessary, and there is neither preexisting evidence of coronary disease nor risk factors for CAD


IndicationsPatients With Congenital Heart Disease (Class I and III only)

II IIa IIb IIIII IIa IIb IIIII IIa IIb IIIIIa IIb III

Before surgical correction of congenital heart disease when chest discomfort or noninvasive evidence is suggestive of associated CAD

Before surgical correction of suspected congenital coronary anomalies such as congenital coronary artery stenosis, coronary arteriovenous fistula, and anomalous origin of left coronary artery

Forms of congenital heart disease frequently associated with coronary artery anomalies that may complicate surgical management

Unexplained cardiac arrest in a young patient In the routine evaluation of congenital heart disease in asymptomatic

patients for whom heart surgery is not planned


IndicationsPatients With CHF (Class I and III only)

II IIa IIb IIIII IIa IIb IIIII IIa IIb IIIIIa IIb III

CHF due to systolic dysfunction with angina or with regional wall motion abnormalities and/or scintigraphic evidence of reversible myocardial ischemia when revascularization is being considered

Before cardiac transplantation CHF secondary to postinfarction ventricular aneurysm or other

mechanical complications of MI.

CHF with previous coronary angiograms showing normal coronary arteries, with no new evidence to suggest ischemic heart disease



There are no absolute contraindications to cardiac catheterization Relative contraindications include:

Coagulopathy (Radial approach can be attempted based on urgency)

Decompensated congestive heart failure Uncontrolled hypertension Pregnancy Inability for patient cooperation Active infection Renal failure Contrast medium allergy

Contraindications


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



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



PA0 Caudal 30

LM

LADDiagonal

Septals

Distal LAD

LCx

LAO 50 Caudal 30

OM

LM

LADDiagonal

Distal LAD

LCx

OM

‘Spider’ viewBest 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 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


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

Prognosis benign

Anomalous LCx from right cuspImage courtesy Dr. Frederick Feit

Anomalous RCA from left cuspImage courtesy Dr. Frederick Feit

LM

RCA

LAD

Prognosis benign Left coronary artery arising from the right sinus of Valsalva - course relative to

great vessels must be defined as interarterial course portends an increased risk of sudden death


Coronary Anomalies

Increased risk of sudden death

Anomalous LCA from right sinus - Inter-arterial Course

Anomalous LCA from right sinus - Retro-aortic course

Prognosis benign

AORTA

PULMONARY ARTERY

AORTA

PULMONARY ARTERY

RCA RCA

LMLM

LAD LAD

LCX

LCX

coronary angiography

Documents

management of patients

invasive strategy

stabilized uanstemi

rescue pciin patients

anginal severity patients

acute chest pain

nonspecific chest pain

accaha guidelines