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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
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Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy
Sternocostal Aspect
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Diaphragmatic Aspect
Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy
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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
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Right Coronary Artery
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
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Right Coronary Artery
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
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Right Coronary Artery
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
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LAO Cranial Angiogram o# RCA
%DA%DA
Acute 3arginalAcute 3arginal
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RAO Angiogram o# RCA
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4ative RCA Lateral !iew
AcuteAcute
3arginal3arginal
3ain RCA3ain RCA
Demonstrating Origin o# Acute 3arginal
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A% Cranial !iew o# Distal RCA
%DA%DA
A!9ro
ove
A!9ro
ove
R%L :R%L :
R%L -R%L -
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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
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Sternocostal Aspect
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Diaphragmatic Aspect
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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*
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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!*
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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
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A% Caudal !iew o# LCA
LADLAD
CircCirc
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SeptalSeptal
LADLAD
C"C"
DiagonalDiagonal
A% Cranial !iew o# LCA
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A% Cranial LCA Angiogram
SeptalSeptal
DiagonalsDiagonals
LADLAD
L3CAL3CA C"C"
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CircCirc
DiagonalDiagonal
LADLAD
LAO Cranial !iew o# LCA
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LAO Caudal !iew o# LCA
CircCirc
LADLAD3edian Ramus3edian Ramus
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Dominance
Definition "#
the coronary artery which reaches the
cru" o# the heart and then gives o## the
%DA Definition $# (Allows #or codominance
the artery which gives o## the %DA as
well as a large posterolateral )ranch
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Le#t
DominantCirculation
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LCA Angiogram
Distal LADDistal LAD
%ro" LAD%ro" LADL3L3
O3O3
Distal C"Distal C"
Occluded 3edian RamusOccluded 3edian Ramus
Dominant C" A% Caudal
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LCA Angiogram2Dominant C" LAO2Caudal
Distal LADDistal LAD
L3L3
%ro" C"%ro" C"
L%DAL%DA
OccludedOccluded
3edian3edian
RamusRamus
%ro" LAD%ro" LAD
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The Coronary Arteries Are Complementary
Large %DA Small LAD
Euge C" (posterolaterals
Small RCA continuation in A!9roove
tc$ etc$ etcG**
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@rap Around LAD
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Short LADHLarge RCA with Apical "tension
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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.
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S!92O32LAO Caudal
Demonstrating 9ra#t Ostium
OstiumOstium
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S!92O3 : A% Caudal
Demonstrating Anastomosis
S!9S!9
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L3A to LAD
Origin #rom le#t su)clavian (A% Cranial
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L3A to LAD
Distal Anastomosis2A% Cranial
L3AL3A
LADLAD
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Le#t Su)clavian Artery Stenosis
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R3A to RCA
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R3A to RCA
O # i S 9
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Occluded Le#t2sided S!9
4 i LCA A% C d l
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4ative LCA A% Caudal
Stump o# originalStump o# original
S!9 to O3 :S!9 to O3 :
S!9 O3
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S!9 to O3
Lesion :Lesion :
Lesion -Lesion -
S!9 O3
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S!9 to O3Slight change o# view to demonstrate
une6uivocal severity o# lesion
Lesion :Lesion :
Lesion -Lesion -
S!9 RCA
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S!9 to RCA
3ultipurpose Techni6ue 2LAO
S!9S!9
l t d %l
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lcerated %la6ue
LCA A% C d l
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LCA A% Caudal
Severe stenosisSevere stenosis
Distal LADDistal LADwith slow #lowwith slow #low
Th ) LAD
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Throm)us n LAD
%ost24T92Throm)us has migrated distally )ut still adherent
Throm)usThrom)us
A% C i l Th ) LAD
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A% Cranial Throm)us n LAD
Throm)usThrom)us
m)oli
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m)oli
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Calci#ied 4ative RCA(LAO Cranial
+Bone sland, Simulating Throm)us
3 di l B id i
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3yocardial Bridging
Almost always LAD
Occurs in '2:- o# patients
sually not hemodynamically signi#icant
ntramyocardial Segment
3 ocardial Bridging
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3yocardial Bridging
LCA2RAO %ro;ection
LAD DiastoleLAD Diastole LAD SystoleLAD Systole
C A t Fi t l
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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
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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
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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*
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Anomalous Origin o# RCA #rom Le#t
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Anomalous Origin o# RCA #rom Le#tCoronary Sinus
Rare
Arises anterior to the origin o# the LCA
ngage with Le#t Amplat
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4ormal and AnomalousOrigins o# the Coronary
Arteries
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Benign Anomalies (1 ' :
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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%&%
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
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7/25/2019 Basic Coronary Anatomy - Paul Fefer, MD.
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