basic coronary anatomy - paul fefer, md

7/25/2019 Basic Coronary Anatomy - Paul Fefer, MD.

1/57

Basic Coronary ArteryAnatomy

Paul Fefer, MD.Interventional Cardiology Unit

Sheba Medical Center, Tel Hashoer

Courtesy of Frederic! Feit, MD

The Cardiovascular Research Foundation Transcatheter Cardiovascular Therapeutics

Medtronic Fellows PCI PrimerMedtronic Fellows PCI Primer


2/57

Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy

Sternocostal Aspect


3/57

Diaphragmatic Aspect

Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy


4/57

77ththAnnual Interventional Cardiology Self-Assessment Course at TCT2!Annual Interventional Cardiology Self-Assessment Course at TCT2!Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy" Frederic# Feit$ M%&%" Frederic# Feit$ M%&%

Right Coronary Artery

OriginRight aortic sinus (lower origin than LCA

CourseDown right A! groove toward cru" o# the heart$ gives

o## %DA (&' #rom which septals arise$ continues inLA! groove giving o## posterior L! )ranches(posterolaterals* %DA may originate morepro"imally$ )i#urcate early or )e small with part o#+its territory, supplied )y an acute marginal )ranch*

Supplies-' to .' o# Le#t !entricle

Basic Anatomy


5/57



Conus Artery

usually very pro"imal/ (0'1 have a separate origin2

courses anteriorly and upward over the R! out#low

tract toward the LAD* 3ay )e an important source o#

collaterals* SA 4odal Artery

(051 usually -nd )ranch o# RCA2courses o)li6uely

)ac7ward through upper portion o# atrial septum and

anteromedial wall o# the RA2supplies SA node$ usually

RA and sometimes LA*

Other Branches


6/57



Right !entricular(Acute 3arginalBranchesArise #rom mid RCA/ supply anterior

R!/ may )e a collateral source* A! 4odal Artery

Arises at or near cru"/ supplies A! node*

%DA

Supplies in#erior wall$ ventricularseptum$ posteromedial papillary muscle*

Other Branches


7/57



LAO (.1 Cranial(.1particularly #or distal )i#urcation (A%Cranial may )e )etter*

RAOmain sha#t/ cranial enhances distal vesselsand very pro"imal/ caudal may help withShepherd8s croo7*

Lateral)i#urcations with R! )ranches2distal)i#urcation$ particularly with cranial*

Optimal !iew(s


8/57


LAO Cranial Angiogram o# RCA

%DA%DA

Acute 3arginalAcute 3arginal


9/57


RAO Angiogram o# RCA


10/57


4ative RCA Lateral !iew

AcuteAcute

3arginal3arginal

3ain RCA3ain RCA

Demonstrating Origin o# Acute 3arginal


11/57


A% Cranial !iew o# Distal RCA

%DA%DA

A!9ro

ove

A!9ro

ove

R%L :R%L :

R%L -R%L -


12/57


Le#t Coronary Artery

Originupper portion o# le#t aortic sinus ;ust )elow the sinotu)ularridge* Typically 12:1 mm in length* Rarely no L3 (separateorigins*

Catheteri2Le#t coronary catheter will #ind the LCAori#ice unless thwarted )y the operator,* =ust in case2other=ud7ins si


13/57

Sternocostal Aspect

77thth

Annual Interventional Cardiology Self-Assessment Course at TCT2!Annual Interventional Cardiology Self-Assessment Course at TCT2!Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy" Frederic# Feit$ M%&%" Frederic# Feit$ M%&%


14/57

Diaphragmatic Aspect

77thth



15/57

77thth


Le#t Anterior Descending Artery

Course

down the anterior interventricular groove2usuallyreaches ape"* n -- o# cases does not reach ape"*

Branches

septals and diagonals2supply lateral wall o# L!$

anterolateral papillary muscle/ . have medianramus (courses li7e :st diagonal*

LAD

Supplies anterolateral$ ape" and septum/ 0>'2''

o# le#t ventricle*


16/57

77thth


Le#t Circum#le" Artery

Origin

#rom distal L3CA* Course

down distal le#t A! groove*

Branches

o)tuse marginal$ posterolaterals2supply posterolateralL!$ anterolateral papillary muscle* SA node artery2.&*

Supplies:'2-' o# L!$ unless dominant (supplies >12'1 o#

L!*


17/57

77thth


Le#t Coronary Artery

A% (.1CaudalL3CA$ pro"imal LAD$ C"$ distal LAD* %oor #or mid LAD2RAO may )e use#ul*

A% (>1CranialL3CA$ LAD$ diagonals$ septals$ distal C"2may need RAO to

separate LAD and C"*

(>'LAO (.' CranialL3CA$ LAD$ diagonals$ septals$ and distal C"*

(>'LAO (.1 CaudalL3CA$ C"$and pro" LAD*

Laterals (cranial$ caudalmay )e help#ul*

Optimal !iews


18/57

77thth


A% Caudal !iew o# LCA

LADLAD

CircCirc


19/57

77thth


SeptalSeptal

LADLAD

C"C"

DiagonalDiagonal

A% Cranial !iew o# LCA


20/57

77thth


A% Cranial LCA Angiogram

SeptalSeptal

DiagonalsDiagonals

LADLAD

L3CAL3CA C"C"


21/57

77thth


CircCirc

DiagonalDiagonal

LADLAD

LAO Cranial !iew o# LCA


22/57

77thth


LAO Caudal !iew o# LCA

CircCirc

LADLAD3edian Ramus3edian Ramus


23/57

77thth


Dominance

Definition "#

the coronary artery which reaches the

cru" o# the heart and then gives o## the

%DA Definition $# (Allows #or codominance

the artery which gives o## the %DA as

well as a large posterolateral )ranch


24/57

Le#t

DominantCirculation

77thth



25/57

77thth


LCA Angiogram

Distal LADDistal LAD

%ro" LAD%ro" LADL3L3

O3O3

Distal C"Distal C"

Occluded 3edian RamusOccluded 3edian Ramus

Dominant C" A% Caudal


26/57

77thth


LCA Angiogram2Dominant C" LAO2Caudal

Distal LADDistal LAD

L3L3

%ro" C"%ro" C"

L%DAL%DA

OccludedOccluded

3edian3edian

RamusRamus

%ro" LAD%ro" LAD


27/57

77thth


The Coronary Arteries Are Complementary

Large %DA Small LAD

Euge C" (posterolaterals

Small RCA continuation in A!9roove

tc$ etc$ etcG**


28/57

77thth


@rap Around LAD


29/57

77thth


Short LADHLarge RCA with Apical "tension


30/57

77thth


BI%ASS 9RAFTS

S!9

Le#t coronary gra#ts generally arise #rom

le#t side o# the aorta* Best cannulated with

=ud7ins8 Right$ 3A$ LCB or 3%*

Right sided gra#ts2arise #rom right side o#the aorta23% usually )est*

3A

don8t #orget to chec7 su)clavians*

%ll distal vessels ust be accounted for& o' notes and old fils are e(treely hel'ful.


31/57

77thth


S!92O32LAO Caudal

Demonstrating 9ra#t Ostium

OstiumOstium


32/57

77thth


S!92O3 : A% Caudal

Demonstrating Anastomosis

S!9S!9


33/57

77thth


L3A to LAD

Origin #rom le#t su)clavian (A% Cranial


34/57

77thth


L3A to LAD

Distal Anastomosis2A% Cranial

L3AL3A

LADLAD


35/57

77thth


Le#t Su)clavian Artery Stenosis


36/57

77thth


R3A to RCA


37/57

77thth


R3A to RCA

O # i S 9


38/57

77thth


Occluded Le#t2sided S!9

4 i LCA A% C d l


39/57

77thth


4ative LCA A% Caudal

Stump o# originalStump o# original

S!9 to O3 :S!9 to O3 :

S!9 O3


40/57

77thth


S!9 to O3

Lesion :Lesion :

Lesion -Lesion -

S!9 O3


41/57

77thth


S!9 to O3Slight change o# view to demonstrate

une6uivocal severity o# lesion

Lesion :Lesion :

Lesion -Lesion -

S!9 RCA


42/57

77thth


S!9 to RCA

3ultipurpose Techni6ue 2LAO

S!9S!9

l t d %l


43/57

77thth


lcerated %la6ue

LCA A% C d l


44/57

77thth


LCA A% Caudal

Severe stenosisSevere stenosis

Distal LADDistal LADwith slow #lowwith slow #low

Th ) LAD


45/57

77thth


Throm)us n LAD

%ost24T92Throm)us has migrated distally )ut still adherent

Throm)usThrom)us

A% C i l Th ) LAD


46/57

77thth


A% Cranial Throm)us n LAD

Throm)usThrom)us

m)oli


47/57

77thth


m)oli


48/57

77

thth


Calci#ied 4ative RCA(LAO Cranial

+Bone sland, Simulating Throm)us

3 di l B id i


49/57

77

thth


3yocardial Bridging

Almost always LAD

Occurs in '2:- o# patients

sually not hemodynamically signi#icant

ntramyocardial Segment

3 ocardial Bridging


50/57

77

thth


3yocardial Bridging

LCA2RAO %ro;ection

LAD DiastoleLAD Diastole LAD SystoleLAD Systole

C A t Fi t l


51/57

77

thth


Coronary Artery Fistula

Origin'1 RCA* Clinical Syndromes CEF$ endocarditis$

ischemia$ and rupture o# aneurysmal #istula*

'1 are asymptomatic* Drainage R!2>:/ RA2-5/ %A2:/

L!2.$ and S!C2:*

Coronary Artery Fistula


52/57

77thth

Annual Interventional Cardiology Self-Assessment Course at TCT2!Annual Interventional Cardiology Self-Assessment Course at TCT2!

Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy" Frederic# Feit$ M%&%" Frederic# Feit$ M%&%

Coronary Artery FistulaLCA2RAO %ro;ection

LAD to %A Fistula

LADLAD

%A%A

FistulaFistula

Anomalo s Origin o# LCA #rom the


53/57

Anomalous Origin o# LCA #rom theRight Sinus o# !alsalva

Rare

Course relative to great vessels is varia)le

and must)e de#ined* # interarterial$

surgical therapy is warranted*

77thth



Anomalous Origin o# RCA #rom Le#t


54/57

Anomalous Origin o# RCA #rom Le#tCoronary Sinus

Rare

Arises anterior to the origin o# the LCA

ngage with Le#t Amplat


55/57

4ormal and AnomalousOrigins o# the Coronary

Arteries

77thth



Benign Anomalies (1 ' :


56/57

77thth



Benign Anomalies (1*'2:

Le#t Circum#le" #rom right Sinus o# !alsalva3ost common +)enign, anomaly

Circum#le" courses )ehind aorta

Eigh Anterior Origin o# RCAA)ove sinotu)ular ridge

Anomalous Circum#le" Artery


57/57

77thth A l I t ti l C di l S lf A t C t TCT2!A l I t ti l C di l S lf A t C t TCT2!

Anomalous Circum#le" Artery

basic coronary anatomy - paul fefer, md

Documents