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

Coronary Angiography

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

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

Optimal Coronary Angiographic

Views: Left Main
Segment
Ostial
Body

Routine

Adjunctive

LAO Caudal

AP Caudal

RAO Caudal
RAO Cranial

AP Caudal

Distal
LAO Caudal
RAO Caudal

LAO Cranial

Left Main: LAO Caudal

Optimal Coronary Angiographic

Views: Left Anterior Descending
Segment
Ostial
Body

Routine

LAO Caudal

Adjunctive

AP/RAO Caudal

RAO Caudal AP Cranial

LAO&RAO Cranial

Distal
RAO
RAO Caudal

LAO Cranial

LAD: RAO Cranial

Coronary Angiography

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

LADDiag Lesions in the AP Cranial

View

AP Cranial: Distal Stent Dissection

Optimal Coronary Angiographic

Views: Circumflex
Segment
Ostial
Body

Routine

LAO Caudal

Adjunctive

AP Caudal

Shallow RAO AP Caudal

LAO
LAO cranial

Distal
Shallow LAO LAO Cranial
Shallow RAO
AP caudal

Coronary Angiography

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

Proximal Ramus Stenosis

Optimal Coronary Angiographic

Views: Right Coronary Artery
Segment

Routine

Ostial/Prox LAO Cranial

AP Caudal

Adjunctive

Lateral(90-110)

Mid Vessel Shallow RAO Lateral

LAO Caudal
Distal Bifurcation

LAO Cranial

PDA Shallow RAO AP Cranial

PLB AP caudal
Lateral Cranial

AP Cranial

Coronary Angiography

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

Coronary Angiography

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

Optimal Coronary Angiographic

Views: Vein Bypass Grafts
Segment

Routine

Adjunctive

Ostial LAD Shallow RAO AP Caudal

RCA
LAO
LAO Caudal
Body

RAO
LAO

Optimal Coronary Angiographic

Views: Bypass Graft Insertion Site
SEGMENT

ROUTINE* ADJUNCTIVE

LAD/Diag AP Cranial
Circ LAO

Lateral

AP Caudal
RAO Cranial

RCA LAO Caudal

RAO Caudal

Lateral

PDA/PLB(Bif)

AP Cranial

Lateral

PDA/PLB (Mid)

LAO Cranial

RAO Caudal

*Similar Views for same area of native vessel

Optimal Coronary Angiographic

Views: Internal Mammary Graft
SEGMENT
Ostial

ROUTINE ADJUNCTIVE

Shallow

RAO

LAO Cranial

Mid Vessel Shallow RAO Lateral

Insertion to:
LAD RAO Cranial
RCA LAO
RAO

Lateral (+/-)

Lateral

Left Subclavian

AP

RAO Cranial

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

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

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

Coronary Angiography

Distal Blood Flow/Collateral

Classification Based on TIMI Trial
TIMI Grade
0

Contrast Flow

(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

(Complete perfusion)

Contrast passes freely into distal at

same visual rate as unaffected
adjacent vessels

Coronary Angiography

Distal Blood Flow/Collateral

Classification Based on TIMI
Trial
Collateral Supply
1
2
3
developed

Adapted from TIMI

Contrast Flow
Absent
Minimal
Well

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

Coronary Angiography

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

50%

Coronary Angiography

Left Circumflex from RCA

Coronary Angiography

Left Main Arising from RCA

Coronary Angiography

Left Main from RCA

Compression
of LM

Angulation
at
origin
of LM

Coronary Angiography

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

Coronary Angiography

LM-Right Sinus of Valsalva

Septal Course

Adapted from Seroth et al. Am J Cardiol 1990;65:891-898

Coronary Angiography

LM-Right Sinus of Valsalva

Retroaortic Course

Adapted from Seroth et al. Am J Cardiol 1990;65:891-898

Coronary Angiography

LM-Right Sinus of Valsalva

Anterior Free Wall

Adapted from Seroth et al. Am J Cardiol 1990;65:891-898

Coronary Angiography

LM-Right Sinus of Valsalva

Interarterial Course

Adapted from Seroth et al. Am J Cardiol 1990;65:891-898

Anomalous LM: Interarterial

Course

Anomalous LM: Interarterial

Course

Anomalous LM: Interarterial

Course