angulated views in coronary angiography,an introductory lecture for cath lab technicians dr...
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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