anatomical basis of coronary intervention

ANATOMICAL BASIS OF

CORONARY INTERVENTIONS

(ARTERIES AND VEINS)

Speaker

Dr Avijit Bhaumik,2nd year MD PGT,Department of Medicine,Medical College, Kolkata

Chairperson

Prof. S. Guha , Head,Department of Cardiology,Medical College,Kolkata

TODAY’S DISCUSSION

• INTRODUCTION

• CORONARY ARTERIAL ANATOMY

• CORONARY ARTERIAL INTERVENTIONS WITH ANATOMICAL CORELATION

• CORONARY VENOUS ANATOMY

• CORONARY VENOUS INTERVENTIONS WITH ANATOMICAL CORELATION

• TAKE HOME MESSAGES

INTRODUCTION

• Coronary arterial interventions play a vital role in treatment of Coronary artery diseases(CAD)

• Stable angina ; Unstable angina/NSTEMI ; STEMI

• Coronary Interventions – PCI, CABG

• Indications for coronary revascularisation

• Syntax score

RIGHT CORONARY ARTERY

• Origin- anterior aortic sinus of aorta• Diameter - 2.5 mm – 5 mm • Course-passes forwards and to the right between

pulmonary trunk and right auricle-passes downwards along right part of AV groove-winds round inferior border of heart-passes upwards and to the left along posteriorpart of AV groove-Reaches crux of heart - anastomoses with LCX artery to the left of crux

RIGHT CORONARY ARTERY

Branches of Right Coronary Artery

• Right conus artery

• Atrial branches

• Anterior ventricular branches( largest one is the acute marginal artery)

• Posterior ventricular branches

• Posterior interventricular(descending) artery

RIGHT CORONARY ARTERY

Right coronary artery supplies

Whole of right atrium

A portion of left atrium(posterior aspect)

Most of right ventricle except a strip along anterior interventricular groove

Postero inferior one third of ventricular septum, adjoining part of left ventricle

SA node (65% cases), AV node (80-90% cases)

Left anterior oblique view showing normal RCA

Partial occlusion of RCA

LEFT CORONARY ARTERY

• Origin - left posterior aortic sinus

• Diameter- 3 mm – 6 mm

• Course - passes behind pulmonary trunk

appears forwards and to the left between the pulmonary trunk and left auricle

it divides into two branches, anterior interventricular and circumflex

no significant branches arises from the trunk

• Left coronary artery supplies Most of the left atrium

Left ventricle except a strip along posterior and inferior surface of heart

Antero superior 2/3 rd of ventricular septum

SA node (35 % cases)

AV node (10-20% cases)

ANTERIOR INTRAVENTRICULAR ARTERY

• Continuation of left coronary artery• Course-Descends along anterior intraventricular

grooveWinds round the incisura apicis cordisAnastomoses with posterior

interventricular artery in posteriorinterventricular groove

• Branches- ventricular branches ( diagonal artery, left conus artery)septal branches

CIRCUMFLEX ARTERY

• Arises from left coronary artery• Course- passes along left part of atrio ventricular groove

winds round left border of heartoccupies posterior part of AV grooveanastomoses with RCA

• Branches-atrial branches,anterior and posterior ventricular branches,left marginal artery,posterior intraventricular artery(10-20% cases),S.A. nodal aretry(35% cases)

Right anterior oblique coronary angiographic view showing LMCA, LAD

and LCX

Occlusion of LAD

Narrowing of LMCA

INCIDENCE OF STENOSIS IN DIFFERENT CORONARY ARTERIES

• Average frequency of narrowing of 3 major arterial trunks are as follows-

LAD -40-50%LCX – 15-20%RCA-30-40%• Other infrequent locations of coronary occlusion

are-LMCADiagonal branch of LADLeft marginal of LCX

ANATOMICAL VARIATIONS OF CLINICAL SIGNIFICANCE

• Ostial position, number

• Absent LMCA, LAD and LCX having ostial origin

• RCA- origin from opposite sinus, split RCA, Shephard’s crook RCA

• Dual LAD

• Dominance, super dominance

• Myocardial bridging

MYOCARDIAL BRIDGING

SHEPHARD’S CROOK CORONARY ARTERY

SYNTAX SCORE(Synergy between PCI with Taxus and cardiac

surgery trial.)

• Angiographic grading tool to determine complexity of coronary artery disease

• Syntax score is used to choose between PCI and CABG for revascularisation

• Includes only anatomical charecteristics of CAD

SYNTAX SCORE

• Points to individual lesion in coronary tree that has >50% diameter narrowinginvessels>1.5mm

• Coronary tree is divided into 16 segments according to AHA classification

SYNTAX SCORE

• Coronary arterial segments discussed

• Clinical relevance of this segments

• Dominance- left/right

• Other anatomic features that determine whether PCI is feasible or not includes

• Aorto ostial lesion

• Tortuisity of vessel

• Lesion length

• Presence of side branch

• Total occlusion

blunt stump

bridging collateral

• Trifurcation

• Bifurcation

• Side branch angulation

Bifurcation Trifurcation

Lesion length > 20mm

Diffuse diseaseThrombus

SYNTAX SCORE

• SYNTAX SCORE is calculated with the help of calculator

• If syntax score< 21 - PCI

• If Syntax score >34 - CABG

• If Syntax score 21-34- PCI/ CABG

• Drawbacks

PERCUTANEOUS CORONARY INTERVENTION

• Andreas gruentzig first performed PTCA in 1977

• Since then various modifications and developments have occurred

• Vascular access- femoral artery

radial artery

brachial artery

• procedure

ENTERING THE OSTIUM

PERCUTANEOUS CORONARY INTERVENTION

PERCUTANEOUS CORONARY INTERVENTION

• ADVANTAGES

Less invasive

Shorter hospital stay

Lower initial cost

Easily repeated

Effective in relieving symptoms

• DISADVANTAGES

Restenosis

Incomplete revascularisation

Relative inefficacy with low LVEF

Limited to specific anatomic subsets

Less favourable outcome in diabetics

CABG

• A graft is used to bypass the stenosedsegment of coronary artery

• Done by midline sternotomy

• Graft is taken from the internal mammary artery or the saphenous vein

• Uncommon graft sites- radial artery, ulnarartery, gastro epiploic artery, inferior epigastric artery

CABG

CABG

• ADVANTAGES

Wider applicability

Ability to achieve complete revascularisation

Favourable outcome in diabetics

Effective in relieving symptoms

• DISADVANTAGES

Cost

Morbidity

Patient preference

CORONARY VENOUS ANATOMY

CORONARY VENOUS ANATOMY

• CORONARY SINUS

Situated in the posterior part of AV groove

receives 60% of venous blood of heart

begins in the left part of AV groove where it receives the great cardiac vein

ends in sinus venarum of right atrium.

the AV nodes lies just above the opening

• Branches- great cardiac veinmiddle cardiac veinsmall cardiac veinposterior vein of the left ventricleoblique vein of left atrium

Veins not draining into coronary sinus-anterior cardiac veinsvenae cordis minimiright marginal vein( occasionally)

CORONARY VENOUS ANATOMY –CLINICAL IMPLICATIONS

• Gateway for left ventricular epicardial lead placement in CRT

• Placement of octapolar or decapolar catheter in coronary sinus during EP study for supraventricular tachycardia

• Coronary sinus blood sampling

• Stem cell transplantation

CORONARY VENOUS SEGMENTS

CRT

CRT

CORONARY SINUS CATHETER IN EP STUDY

STEM CELL TRANSPLANT

TAKE HOME MESSAGES

• PCI AND CABG are the revascularisationprocedures used.

• ANATOMY of the coronary artery play vital role in choosing between PCI and CABG

• Some anatomic variations causes difficulty in PCI

• CRT, EP studies, stem cell transplantation make use of the coronary venous anatomy.

Thank you