anatomical basis of coronary intervention
TRANSCRIPT
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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
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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
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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
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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
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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
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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)
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Left anterior oblique view showing normal RCA
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Partial occlusion of RCA
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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
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• 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)
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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
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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)
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Right anterior oblique coronary angiographic view showing LMCA, LAD
and LCX
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Occlusion of LAD
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Narrowing of LMCA
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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
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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
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MYOCARDIAL BRIDGING
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SHEPHARD’S CROOK CORONARY ARTERY
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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
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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
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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
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• Aorto ostial lesion
• Tortuisity of vessel
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• Lesion length
• Presence of side branch
• Total occlusion
blunt stump
bridging collateral
• Trifurcation
• Bifurcation
• Side branch angulation
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Bifurcation Trifurcation
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Lesion length > 20mm
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Diffuse diseaseThrombus
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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
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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
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ENTERING THE OSTIUM
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PERCUTANEOUS CORONARY INTERVENTION
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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
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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
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CABG
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CABG
• ADVANTAGES
Wider applicability
Ability to achieve complete revascularisation
Favourable outcome in diabetics
Effective in relieving symptoms
• DISADVANTAGES
Cost
Morbidity
Patient preference
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CORONARY VENOUS ANATOMY
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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
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• 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)
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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
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CORONARY VENOUS SEGMENTS
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CRT
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CRT
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CORONARY SINUS CATHETER IN EP STUDY
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STEM CELL TRANSPLANT
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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.
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Thank you