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Angulated views in coronary angiography,an introductory lecture for cath lab technicians dr awadhesh

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LPS Institute of Cardiology Kanpur UP India
LPS Institute of Cardiology Kanpur UP India

Angulated views in coronary angiography,an introductory lecture for cath lab technicians dr awadhesh

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Angulated views in coronary angiography An Indroductory lecture for cath lab technicians Dr Awadhesh Kumar Sharma MD(Gold Medalist),DM Cardiology
Dr Awadhesh Kumar Sharma  Dr.Awadhesh Kumar Sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college Jhansi.Then he did his superspecilization degree DM in Cardiology from PGIMER & DR Ram Manohar Lohia Hospital New Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM. He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Hon. Mayawati in 2009.He is also receiver of GEMS international award. He had many national & international publications. He had special interest in both invasive & non invasive cardiology. He had performed more then 5000 invasive cardiac intervention procedures successfully till date including coronary angiography, simple & complex angioplasty, peripheral vessels angiography & angioplasty, carotid angiography & angioplasty,ASD ,PDA device closures, Mitral & pulmonary valvotomy. He is also in editorial board of many national & international journal- Journal of clinical medicine & research(JCMR),Clinical cardiology update, EC Pulmonology and Respiratory Medicine. He is also active member of reviewer board of many journals. He is also international associate fellow of American college of cardiology. He is active member of many professional bodies including Indian MedicalAssociation, Cardiological Society of India,APVIC, ICC,API. He had worked in NABHApproved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist since 2014-2016. Currently he is working asAssistant Professor of cardiology at LPS Institute of Cardiology, GSVM Medical college, Kanpur(UP)under Govt of UP.
Cineangiographic equipments  A Generator  X Ray tube – under the patients table  Image Intensifier- attached to a positioner such as C-arm, over the patients table  Optical system  Digital convertor  TV monitors  Control Unit
Angulated views in coronary angiography,an introductory lecture for cath lab technicians dr awadhesh
CranialView- image intensifier is tilted towards the head of the patient CaudalView- image intensifier is tilted down toward the feet of the patient APView – image intensifier is in central position LateralView – image intensifier is on left side of the patient horizontally at body level
Importance of angulated views  Proper delineation of coronary & peripheral vascular anatomy  Origin & course of vessel  Eccentric lesion
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 Views RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal  Best for visualizing-  Left main bifurcation  Proximal LAD  Proximal to mid LCx Left Coronary Artery
Standard Angiographic Views Left Coronary Artery RAO 20 Caudal 20 LM LAD Diagonal Septals Distal LAD 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 Distal LAD fills by collaterals LAD Best for visualization of LM bifurcation and proximal LAD and LCx
 LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial Best for visualizing  Mid and distal LAD  Distal LCx in a left dominant system  Separates out the septals from the diagonals Left Coronary Artery
Standard Angiographic Views Left Coronary Artery LAO 50 Cranial 30 LM LAD Diagonal Septals 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
Left Coronary Artery  PA-Cranial view: 00 lateral and 300 cranial  Best for visualizing -  Mid LAD  Distal LAD
Left Coronary Artery  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
Left Coronary Artery LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal Best for visualizing-  Left main,  Proximal LAD  Proximal LCx  Spider view
Standard Angiographic Views Left Coronary Artery PA0 Caudal 30 LM LAD Diagonal Septals Distal LAD LCx LAO 50 Caudal 30 OM LM LAD Diagonal Distal LAD LCx OM ‘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
Left Coronary Artery PA-Caudal view: 00 lateral and 200 to 300 caudal Best for visualizing  Distal left main bifurcation  Proximal LAD  Proximal to mid LCx
Left Coronary Artery PA projection: 00 lateral and 00 cranio-caudal Best for visualizing  Ostium of the left main
Left lateral view: Best for visualizing Proximal LCx, Proximal and distal LAD Also good for visualizing LIMA to LAD anastomotic site Left Coronary Artery
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  Left lateral view: Left Lateral 900  Ostium of the RCA  Midportion of the RCA  Separation of RCA with its RV branches Right Coronary Artery
Standard Angiographic Views Right Coronary Artery LAO 30 Proximal RCA PDA Distal 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
RAO and LAO Ventriculography: RAOVentricle  LAOVentricle
Left Ventriculogram Systolic View RAO
Left Ventriculogram Diastolic View RAO
Cerebral circulation APView- Common carotid,External carotid, Internal carotid,Vertebral arteries LateralView- Bifurcation of Common carotid artery into External carotid & Internal carotid artery
Commonly used angiographic views  Most favorable angulation for iliac angiography is the contralateral oblique angle, generally 30 to 40 °  The optimal view for the common femoral bifurcation is 30 to 45° of ipsilateral oblique angulation  SFA can be imaged in an anteroposterior view with the addition of an oblique angle if a stenosis is suspected.  The popliteal artery, tibeoperoneal trunk, and trifurcation are best imaged in an ipsilateral oblique angle (30°).  Infrapopliteal runoff can be performed in either an anteroposterior or an ipsilateral oblique projection N Engl J Med. 2006;354:379 –386 Vasc Endovascular Surg. 2002;36:439–445 LAO 30
Angulated views in coronary angiography,an introductory lecture for cath lab technicians dr awadhesh

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Angulated views in coronary angiography,an introductory lecture for cath lab technicians dr awadhesh

  • 1. Angulated views in coronary angiography An Indroductory lecture for cath lab technicians Dr Awadhesh Kumar Sharma MD(Gold Medalist),DM Cardiology
  • 2. Dr Awadhesh Kumar Sharma  Dr.Awadhesh Kumar Sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college Jhansi.Then he did his superspecilization degree DM in Cardiology from PGIMER & DR Ram Manohar Lohia Hospital New Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM. He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Hon. Mayawati in 2009.He is also receiver of GEMS international award. He had many national & international publications. He had special interest in both invasive & non invasive cardiology. He had performed more then 5000 invasive cardiac intervention procedures successfully till date including coronary angiography, simple & complex angioplasty, peripheral vessels angiography & angioplasty, carotid angiography & angioplasty,ASD ,PDA device closures, Mitral & pulmonary valvotomy. He is also in editorial board of many national & international journal- Journal of clinical medicine & research(JCMR),Clinical cardiology update, EC Pulmonology and Respiratory Medicine. He is also active member of reviewer board of many journals. He is also international associate fellow of American college of cardiology. He is active member of many professional bodies including Indian MedicalAssociation, Cardiological Society of India,APVIC, ICC,API. He had worked in NABHApproved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist since 2014-2016. Currently he is working asAssistant Professor of cardiology at LPS Institute of Cardiology, GSVM Medical college, Kanpur(UP)under Govt of UP.
  • 3. Cineangiographic equipments  A Generator  X Ray tube – under the patients table  Image Intensifier- attached to a positioner such as C-arm, over the patients table  Optical system  Digital convertor  TV monitors  Control Unit
  • 5. CranialView- image intensifier is tilted towards the head of the patient CaudalView- image intensifier is tilted down toward the feet of the patient APView – image intensifier is in central position LateralView – image intensifier is on left side of the patient horizontally at body level
  • 6. Importance of angulated views  Proper delineation of coronary & peripheral vascular anatomy  Origin & course of vessel  Eccentric lesion
  • 7. 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
  • 8. Standard Angiographic Views RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal  Best for visualizing-  Left main bifurcation  Proximal LAD  Proximal to mid LCx Left Coronary Artery
  • 9. Standard Angiographic Views Left Coronary Artery RAO 20 Caudal 20 LM LAD Diagonal Septals Distal LAD 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 Distal LAD fills by collaterals LAD Best for visualization of LM bifurcation and proximal LAD and LCx
  • 10.  LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial Best for visualizing  Mid and distal LAD  Distal LCx in a left dominant system  Separates out the septals from the diagonals Left Coronary Artery
  • 11. Standard Angiographic Views Left Coronary Artery LAO 50 Cranial 30 LM LAD Diagonal Septals 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
  • 12. Left Coronary Artery  PA-Cranial view: 00 lateral and 300 cranial  Best for visualizing -  Mid LAD  Distal LAD
  • 13. Left Coronary Artery  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
  • 14. Left Coronary Artery LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal Best for visualizing-  Left main,  Proximal LAD  Proximal LCx  Spider view
  • 15. Standard Angiographic Views Left Coronary Artery PA0 Caudal 30 LM LAD Diagonal Septals Distal LAD LCx LAO 50 Caudal 30 OM LM LAD Diagonal Distal LAD LCx OM ‘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
  • 16. Left Coronary Artery PA-Caudal view: 00 lateral and 200 to 300 caudal Best for visualizing  Distal left main bifurcation  Proximal LAD  Proximal to mid LCx
  • 17. Left Coronary Artery PA projection: 00 lateral and 00 cranio-caudal Best for visualizing  Ostium of the left main
  • 18. Left lateral view: Best for visualizing Proximal LCx, Proximal and distal LAD Also good for visualizing LIMA to LAD anastomotic site Left Coronary Artery
  • 19. 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  Left lateral view: Left Lateral 900  Ostium of the RCA  Midportion of the RCA  Separation of RCA with its RV branches Right Coronary Artery
  • 20. Standard Angiographic Views Right Coronary Artery LAO 30 Proximal RCA PDA Distal 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
  • 24. Cerebral circulation APView- Common carotid,External carotid, Internal carotid,Vertebral arteries LateralView- Bifurcation of Common carotid artery into External carotid & Internal carotid artery
  • 25. Commonly used angiographic views  Most favorable angulation for iliac angiography is the contralateral oblique angle, generally 30 to 40 °  The optimal view for the common femoral bifurcation is 30 to 45° of ipsilateral oblique angulation  SFA can be imaged in an anteroposterior view with the addition of an oblique angle if a stenosis is suspected.  The popliteal artery, tibeoperoneal trunk, and trifurcation are best imaged in an ipsilateral oblique angle (30°).  Infrapopliteal runoff can be performed in either an anteroposterior or an ipsilateral oblique projection N Engl J Med. 2006;354:379 –386 Vasc Endovascular Surg. 2002;36:439–445 LAO 30