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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3597_Библиотеки_им_академика_М_И_Перельмана
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3 —
Coronary Angiography and Ventriculography 103
60°
60°
AO
R
30°
30°
CR
C
Figure 3-1, cont’d
from Paulin S: Terminology for radiographic projections in cardiac angiography. Cathet Cardiovasc Diagn 7:341–344, 1981.)
A
C, Cranial (CR) and caudal (CA) oblique views. (Redrawn
40°
L
20°
CA
40°
20°
AO
A
Heart shape
AP
A
LAO
B
C
Figure 3-2 A, Anterior-posterior (AP) view of the hear t (closed fist) in the
chest. B, AP view of the left ventricle (LV) shape (open hand) in the chest.
Right diagrams, The approximate shapes as might be seen on x-ray. C, Left
anterior oblique (LAO): The left shoulder forward rotation causes foreshortening of the LV with the apex toward the viewer and rounding of the cardiac
silhouette (right diagram, L AO). D, Right anterior oblique (RAO): The right
shoulder for ward causes the heart to elongate as it rotates with the tip of
the heart to the left side. Right diagram, The LV image as it might appear
on x-ray. (Reprinted with permission from Kern M: Cath Lab Digest 19(8),
2011, copyright HMP Communications.)
AP
RAO
D
AP
LAO RAO
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Coronary Angiography and Ventriculography
AP
A
1
2
4
3
LAO
RAO
1
2
5
4
3
B
Figure 3-3
changes from anterior-posterior (AP) to left anterior oblique (L AO) and right
anterior oblique (RAO). B, Cineangiographic frames of left ventriculograms
in the LAO (left) and RAO (right). LAO segments: 1, Basal; 2, lateral; 3, apical;
and 4, septal. RAO segments: 1, Anterior basal; 2, anterior; 3, apical;
4, inferior; 5, inferior basal. (Reprinted with permission from Kern M: Cath
Lab Digest 19(8), 2011, copyright HMP Communications.)
projection, whether seen on a plain chest x-ray or on fluoroscopy or
ventriculography during cardiac catheterization (see Fig. 3-3, B).
A, Left ventricle (LV) diagrams in patients as the LV shape
The Left Coronary Arteries: Left Anterior
Oblique Views
By placing the left-hand fingers over the clenched right fist, the index
finger becomes the left anterior descending (LAD) artery and runs
over the knuckles, which represent the anterior interventricular groove
(Fig. 3-4). The middle finger is spread lying on the finger joints and
represents the circumflex (CFX) artery. The thumb runs horizontal to
the wrist joint and represents the initial course of the RCA arising from
the right sinus of Valsalva.
Left Coronary Artery with Left Anterior
Oblique Cranial and Caudal Angulations
In cranial angulation, the II moves toward the head of the patient
and produces a downward tilt of the LAO view, exaggerating the LM
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Coronary Angiography and Ventriculography 105
RCA
LAD
Figure 3-4 Top left, Fingers of the left hand represent the coronary arter-
ies. The colored bars below depict the coronary ar teries of the drawing in
the center. When placed over the heart (fist), the lef t anterior descending
(LAD) (orange, index finger) runs down the anterior interventricular groove.
The circumflex (CF X) artery (yellow, middle finger) runs over the lef t side of
the fist. The proximal portion of the right coronary arter y (RCA) (blue, thumb)
starts at the top of the fist, runs to the wrist, and then runs down the
atrioventricular (AV) groove (wrist joint). The posterior descending artery
(PDA) is shown in the heart illustration. Top right, Coronar y ar teries (fingers)
are shown with the heart (fist) removed in the anterior-posterior (AP) projection. Green block, The lef t main (LM) arter y segment position. Note that the
colored dots (orange for LAD, yellow for CFX, green for LM, and blue for RCA)
correspond to the same color codes used in Figures 3-5 through 3-7.
(Reprinted with permission from Kern M: Cath Lab Digest 19(8), 2011,
copyright HMP Communications.)
LM
CFX
CFX
segment but keeping the relationship between LAD and CFX almost
the same (Fig. 3-5, A).
In caudal angulation, the II moves toward the foot of the patient.
This position views the coronary arteries from underneath, tipping the
LAO view upward to produce a branching appearance that some refer
to as the “spider” view. Figure 3-5, B, and similar images provide a
computed tomography angiography (CTA) reconstruction of the coronary arteries, with the lower panels showing a subtracted image duplicating what would be seen on traditional coronary angiography in the
catheterization laboratory. The lower right panel of Figure 3-5, B,
shows the LAO-caudal angulation and is called the “spider” view for
obvious reasons.
The Left Coronary Arteries: Right Anterior
Oblique Projections
In the LAO projection (see Fig. 3-5), the LAD (index finger) is on the
right side and the CFX (middle finger) is on the left side. When rotated
over to RAO, the position of the fingers (LAD/CFX) changes the orientation such that the LAD is now on the left and the CFX is in the middle
or more rightward than in the LAO view (Fig. 3-6, A).
The RAO with caudal angulation (see Fig. 3-6, A, top left) tips the
CFX downward, separating it further from the LAD. For the RAO with
cranial angulation (see Fig. 3-6, A, top right), the CFX is tipped upward,
foreshortened, and overlapped with the LAD. Cranial views are best
used to see the LAD and diagonals, whereas caudal views are best to
see the CFX and LM segments. Figure 3-6, B, shows the angiograms of
the RAO-caudal and -cranial angulations.
LAO, cranial
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LAO, caudal
LM
LAD
CFX
LAD
A
LAO, cranial LAO, caudal
CFX
LM
B
Figure 3- 5 A, Coronary finger models showing left anterior oblique (L AO)
with cranial (left) and caudal (right) angulations. The coronary arteries
(fingers) are tipped downward as the image intensifier (II) moves toward the
head (cranially). The arteries are tipped upward (right) as the II moves toward
the feet (caudally). Green block, The left main (LM) artery segment position.
(Orange blocks, Lef t anterior descending [LAD] artery; yellow blocks, circum flex [CFX] arter y.) B, Computed tomography angiography (CTA) reconstruction
of left coronary ar teries in LAO-cranial (lef t) and LAO-caudal (right) angulations. Bottom, Simulations of images seen on contrast angiography. Lower
right, The left coronary ar tery (LCA) in the LAO-caudal view is called the
“spider” view for obvious similarities to the arachnid of the same name.
Color codes are the same as shown in Figures 3-4 to 3 -7. (Reprinted with
permission from Kern M: Cath Lab Digest 19(8), 2011, copyright HMP
Communications.)
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Coronary Angiography and Ventriculography 107
RAO, caudal
RCA
A
LM
CFX
CFX
LAD
RAO, caudal
RAO, cranial
LAD
LM
CFX
LAD
RAO, cranial
B
Figure 3-6
(RAO) with caudal angulation. As the right shoulder moves anteriorly, the
position of the lef t anterior descending (LAD) arter y (red) moves from the
left side to the right side of the cardiac silhouette. The circumflex (CF X)
artery (yellow) moves toward the left side or center of the hear t. Top right,
RAO with cranial angulation showing the turning upward with foreshortening
of the CFX artery. In most left coronary artery (LCA) images with RAO cranial,
there is overlapping of the proximal L AD and CFX (see Fig. 3-3, B). B, Computed tomography angiography (CTA) reconstruction of left coronar y arteries
in the R AO- caudal (left) and RAO -cranial (right) angulations. Bottom, Simulations of the images that are seen on contrast angiography. Note the overlapping of the proximal L AD and CFX. Color codes are the same as shown in
Figures 3-4 to 3-7. (Reprinted with permission from Kern M: Cath Lab Digest
19(8), 2011, copyright HMP Communications.)
A, Top left, The coronar y arteries in the right anterior oblique
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Coronary Angiography and Ventriculography
The Right Coronary Artery and Posterior
Descending Artery: Left Anterior Oblique
and Right Anterior Oblique
Using the left hand over the fist, the thumb represents the proximal
part of the RCA. The RCA continues down the wrist (atrioventricular
[AV] groove) to the posterior descending artery (PDA) portion of the
RCA, which runs along the inferior interventricular groove. The PDA
along the bottom of the heart can be represented by the index finger
(Fig. 3-7, A). In the LAO cranial angulation, the PDA runs along the
bottom of the heart and is tipped downward to better visualize the
length without foreshortening (Fig. 3-7, A). In the RAO without cranial
or caudal angulation, the PDA is seen lengthwise running from the
base to the apex of the heart (Fig. 3-7, A, right panels). Figure 3-7, B,
shows the CTA and contrast-filled angiograms of the RCA in the LAOcranial and RAO projections.
Using this model, it should be easy to visualize and remember the
coronary and ventriculographic images in the different oblique views
with and without cranial and caudal angulations.
Left Coronary Artery Imaging
1. The AP-caudal or shallow RAO view displays the LMCA in its entire
perpendicular length (Fig. 3-8). In this view, the proximal segments
of the LAD and left CFX arteries are displayed, but the branches
are overlapped. After the LM segment, slight RAO or LAO angulation may be necessary to clear the density of the vertebrae, and the
catheter shaft in the thoracic descending aorta, from covering the
artery.
2. The LAO-cranial view also shows the LMCA (slightly foreshort-
ened) and the LAD and its diagonal branches. Septal (coursing to
the left) and diagonal (to the right) branches are separated clearly.
The CFX artery and marginal branches are foreshortened and overlapped, although the posterolateral and posterior descending
branches of left-dominant circulation are displayed clearly. Deep
inspiration, which moves the density of the diaphragm down and
out of the field, is helpful. The LAO angle (>30 degrees) should be
set so that the LAD artery course is parallel to the spine and stays
in the “lucent wedge” bordered by the spine on the medial edge
and the curve of the diaphragm. Cranial angulation tilts the LMCA
down and permits a view of the LAD/CFX bifurcation. LAO-cranial
angulation that is too steep or inspiration that is too shallow produces considerable overlapping with the diaphragm and liver,
degrading the image.
3. The RAO-caudal view shows LMCA bifurcation, perpendicular to
that of the LAO-cranial angle. The origin and course of the CFX/
obtuse marginal branches, ramus intermedius branch, and proximal LAD segment are seen clearly. This view is one of the two best
for visualization of the CFX artery. The LAD arter y beyond the
proximal segment is obscured by overlapped diagonals; however,
the apical segment of the LAD artery is displayed clearly.
4. The RAO-cranial view is used to see the origins of the diagonals
along the mid and distal LAD artery. Diagonal branch bifurcations
are well visualized. The diagonal branches are projected upward.
The proximal LAD and CFX usually are overlapped. Marginal
branches may overlap, and the CFX artery is foreshortened, but
posterolateral branches are well visualized.
5. The LAO-caudal view (“spider” view) shows the LMCA (foreshort-
ened) and bifurcation of the LMCA into the CFX and LAD arteries.
Proximal and mid portions of the CFX artery are usually seen
clearly with the origins of obtuse marginal branches. Poor image
quality may be caused by an overlapping of the diaphragm and
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Coronary Angiography and Ventriculography 109
LAO, cranial
A
RAO
PDA
B
Figure 3 -7
coronary artery (RCA) runs along the inferior interventricular groove. Top left,
In the left anterior oblique (LAO) -cranial angulation, the PDA runs along the
bottom of the heart and is tipped downward to better visualize the length
without foreshortening. Top right, In the right anterior oblique (RAO) without
cranial or caudal angulation, the PDA is seen lengthwise running from the
base to the apex of the hear t. B, Computed tomography angiography (CTA)
reconstruction of the RCA in the LAO -cranial (left) and RAO (no cranial or
caudal) (right) angulations. Bottom, Simulations of the images that are seen
on contrast angiography. Color codes are the same as shown in Figures 3- 4
to 3 -6. (Reprinted with permission from Kern M: Cath L ab Digest 19(8),
2011, copyright HMP Communications.)
A, The posterior descending arter y (PDA) por tion of the right
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Coronary Angiography and Ventriculography
A
B
C D
E
Figure 3-8 Frames from coronar y angiograms in several standard views.
A, Lef t coronary artery (LCA) left anterior oblique (L AO)- cranial projection;
B, L AO-caudal projection; C, right anterior oblique (RAO)- caudal projection;
D, RAO -cranial projection; E , right coronar y ar tery (RCA) in L AO- cranial pro-
jection; F, RCA in RAO-straight projection.
F
spine. Good separation of the vessel is more difficult in vertically
displaced hearts, such as those in patients with chronic obstructive
pulmonary disease, and more angulation is required to obtain an
unobstructed view. The LAD artery is considerably foreshortened
in this view.
6. A lateral view (II rotated 90 degrees, parallel with the floor) is the
best view to show the mid and distal LAD arteries. The LAD and
CFX arteries are well separated. Diagonals are usually overlapped.
The (ramus) intermedius branch course is well visualized. This
view best shows insertions of bypass grafts into the mid LAD artery.
Occasionally, slight caudal or cranial angulation is needed to visualize the segment of interest.
Right Coronary Imaging
In contrast to left coronar y angiography, selective engagement of
the RCA requires torqueing of the catheter anteriorly and to the right
(Fig. 3-8, E and F ). The catheter must be advanced to the right coronary cusp and then pulled back slowly while applying clockwise
torque. A “push-pull” motion while torqueing the catheter will help
transmit the twisting down to the catheter tip. As with cannulation of
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the LM, the operator should observe the pressure waveform. Damping
signals engagement of the conus branch. Injection of this vessel can
lead to ventricular fibrillation. Once selective coronary engagement is
accomplished, intracoronary nitroglycerin is often given to prevent or
alleviate catheter-induced spasm. If spasm does occur or if an ostial
lesion is suspected, a smaller-diameter catheter might be used. If selective engagement of the RCA using standard catheters is not successful,
consider using special catheters, such as 3DR or no-torque RCA catheters. Anomalous positions of the RCA should be considered when
one cannot find the RCA in the usual location in the right sinus of
Valsalva. A high anterior takeoff of the RCA might be present. If the
RCA cannot be found, a review of left coronary angiography should
be examined for unsuspected collateral flow or the RCA potentially
coming off the left coronary cusp.
1. The LAO-cranial view shows the origin of the RCA, the entire length
of the mid RCA, and the PDA bifurcation (crux) (see Figs. 3-3 and
3-4). Cranial angulation tilts the PDA down to see vessel contour
and to reduce foreshortening. Deep inspiration is necessary to
clear the diaphragm. The PDA and posterolateral branches are
slightly foreshortened in this view.
2. The RAO view (no cranial or caudal angulation is generally necessary) shows the mid RCA and the length of the PDA and posterolateral branches. Septal branches coursing upward from the PDA,
supplying occluded LAD artery via collaterals, may be clearly identified. The posterolateral branches are overlapped and may need
the addition of a cranial view.
3. The AP-cranial view shows the origin of the RCA. The mid segment
is foreshortened. However, this is the best view to display the posterior descending and posterolateral branches of a dominant RCA
system as well as the size of a collateralized LAD artery.
4. The lateral view also shows the RCA origin (especially in patients
with more anteriorly oriented orifices) and mid RCA. The PDA and
posterolateral branches are foreshortened.
Technical note: Because of individual variations in anatomy,
small (1 to 2 mL) test injections during patient inspiration help the
operator obtain the appropriate oblique and axial (cranial/caudal)
angulations and setup for panning.
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Coronary Angiography and Ventriculography 111
Bypass Graft Angiography
In patients who have undergone coronary artery bypass graft (CABG)
surgery, review of the operative report is important. The number and
type of grafts should be noted, particularly if there are arterial grafts
and they are in situ (right internal mammary artery [RIMA] or left
internal mammary artery [LIMA]) or harvested (often radial artery).
The proper technique to engage these grafts depends on the type of
graft.
Left Internal Mammary
Angiography
Selective injection of the LIMA is required for any patient who had this
graft used for CABG (typically to the LAD). The LIMA is a branch of
the left subclavian arter y and is most easily accessed using the left
radial approach. From the femoral approach, selective intubation of
the left subclavian in an LAO projection (Fig. 3-9) using an internal
mammary (IM) catheter can be performed after passing the catheter
into the subclavian artery over a J-wire. Marked tortuosity of the proximal subclavian artery may require a Wholey or Terumo Glidewire to
permit passage of the IM catheter into the subclavian artery. There is
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Coronary Angiography and Ventriculography
1
4
2
3
BA
DC
Figure 3 -9 A, Catheterization of the internal mammar y (IM) ar teries.
B, 1, To catheterize the lef t internal mammar y artery (LIMA), the catheter
is located in the aortic arch in a neutral position, with its tip pointing downward. The catheter is rotated counterclockwise until it falls into the left
subclavian artery. 2, The catheter is advanced with a slight anterior rotation
until it engages the origin of the LIMA. 3, The right internal mammar y artery
(RIMA) is entered by counterclockwise rotation of the catheter at the origin
of the right innominate ar tery and advanced until the origin of the RIMA is
engaged. 4, A guidewire is inserted in the IM graft catheter until it is passed
into the left subclavian ar tery. C, The catheter is advanced over the guidewire and then removed, withdrawing the catheter into the IM arter y (IMA).
D, Positioning of the IMA catheter to engage the RIMA. (B, From Tilkian AG,
Daily EK: Cardiovascular procedures: Diagnostic techniques and therapeutic
procedures, St Louis, 1986, Mosby. D, From King SB, Douglas JS, Jr: Coro nary arteriography and angioplasty, New York, 1985, McGraw-Hill.)
also an IM catheter that often permits easier cannulation of the LIMA.
Any pressure gradient between aortic and subclavian arteries should
be noted because a subclavian stenosis with a LIMA can lead to anterior wall ischemia. Subclavian stenosis can be stented with high
success and low procedural complication rates. Selective LIMA
engagement can be performed in AP, RAO, or LAO. Turning the
patient’s head to the right or left can sometimes assist in LIMA intubation. When selective angiography of the LIMA is not possible because
of extreme tortuosity, nonselective injection of the left subclavian
artery can be obtained with the brachial artery occluded with a blood
pressure cuff inflated to suprasystolic pressure.
The best views for imaging the LIMA-LAD graft are the same as
those used for evaluation of the LAD (i.e., RAO- and LAO-cranial projections). The lateral view is especially useful to visualize LIMA-LAD
anastomosis and may help determine whether scar tissue has formed
tacking the LIMA to the sternum, a finding important to surgeons planning a reoperation with a second sternotomy.
Right Internal Mammary
Coronary Angiography
The RIMA is a branch of the right subclavian artery that arises from
the innominate artery. Selective angiography of the RIMA is required
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