Angulated views in coronary angiography

An Indroductory lecture for cath lab technicians

Angulated views in coronary angiography

An Indroductory lecture for cath lab technicians

Dr Awadhesh Kumar SharmaDM Cardiology

PGIMER &Dr RML Hospital,New Delhi

Cineangiographic equipmentsA GeneratorX Ray tube – under the patients table Image Intensifier- attached to a

positioner such as C-arm, over the patients table

Optical systemDigital convertorTV monitorsControl Unit

Cranial View- image intensifier is tilted towards the head of the patient

Caudal View- image intensifier is tilted down toward the feet of the patient

AP View – image intensifier is in central position

Lateral View – image intensifier is on left side of the patient horizontally at body level

Importance of angulated viewsProper delineation of coronary &

peripheral vascular anatomyOrigin & course of vessel Eccentric lesion

Standard Angiographic ViewsStandard 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 ViewsStandard 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 ViewsStandard 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-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 ViewsStandard Angiographic ViewsLeft Coronary Artery

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

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 ViewsStandard Angiographic ViewsLeft Coronary Artery

PA0 Caudal 30

LM

LADDiagonal

Septals

Distal LAD

LCx

LAO 50 Caudal 30

OM

LM

LADDiagonal

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 ViewsStandard 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 ViewsStandard 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

RAO and LAO Ventriculography:

RAO Ventricle LAO Ventricle

Left VentriculogramSystolic ViewRAO

Left VentriculogramDiastolic ViewRAO

Cerebral circulation

AP View- Common carotid,External

carotid, Internal carotid,Vertebral

arteries

Lateral View- Bifurcation of

Common carotid artery into

External carotid & Internal carotid

artery

Commonly used angiographic viewsMost 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 –386Vasc Endovascular Surg. 2002;36:439–445

LAO 30