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Basic Coronary Artery Anatomy PowerPoint Presentation

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Description : Check out this medical presentation on Coronary Arteries, which is titled "Basic Coronary Artery Anatomy", to know about the anatomy of coronary artery.

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Slide 1-

Basic Coronary Artery Anatomy Paul Fefer, MD. Interventional Cardiology Unit Sheba Medical Center, Tel Hashomer Courtesy of Frederick Feit, MD The Cardiovascular Research Foundation Transcatheter Cardiovascular Therapeutics Medtronic Fellows PCI Primer
Slide 2-

Sternocostal Aspect
Slide 3-

Diaphragmatic Aspect
Slide 4-

Sternocostal Aspect
Slide 5-

Sternocostal Aspect
Slide 6-

Right Coronary Artery Origin Right aortic sinus (lower origin than LCA) Course Down right AV groove toward crux of the heart, gives off PDA (85%) from which septals arise, continues in LAV groove giving off posterior LV branches (posterolaterals). PDA may originate more proximally, bifurcate early or be small with part of “its territory” supplied by an acute marginal branch. Supplies 25% to 35% of Left Ventricle Basic Anatomy
Slide 7-

Right Coronary Artery Conus Artery usually very proximal; (~50% have a separate origin)-courses anteriorly and upward over the RV outflow tract toward the LAD. May be an important source of collaterals. SA Nodal Artery (~60%) usually 2nd branch of RCA-courses obliquely backward through upper portion of atrial septum and anteromedial wall of the RA-supplies SA node, usually RA and sometimes LA. Other Branches
Slide 8-

Right Coronary Artery Right Ventricular (Acute Marginal) Branches) Arise from mid RCA; supply anterior RV; may be a collateral source. AV Nodal Artery Arises at or near crux; supplies AV node. PDA Supplies inferior wall, ventricular septum, posteromedial papillary muscle. Other Branches
Slide 9-

Right Coronary Artery Judkins’ 4-right; clockwise rotation-works 90% of the time. Adjust catheter size to aorta. Other tools—Amplatz, Noto, Williams Catheterization Tools and Techniques
Slide 10-

Right Coronary Artery LAO (30) Cranial(30) particularly for distal bifurcation (AP Cranial may be better). RAO main shaft; cranial enhances distal vessels and very proximal; caudal may help with Shepherd’s crook. Lateral bifurcations with RV branches-distal bifurcation, particularly with cranial. Optimal View(s)
Slide 11-

LAO Cranial Angiogram of RCA PDA Acute Marginal
Slide 12-

RAO Angiogram of RCA
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Native RCA Lateral View Demonstrating Origin of Acute Marginal
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AP Cranial View of Distal RCA PDA AV Groove RPL 1 RPL 2
Slide 15-

RAO Angiogram of Conus Branch LAD
Slide 16-

Left Coronary Artery Origin upper portion of left aortic sinus just below the sinotubular ridge. Typically 0-10 mm in length. Rarely no LM (separate origins). Catheterization Technique “The Judkins’ 4-Left coronary catheter will find the LCA orifice unless thwarted by the operator”. Just in case-other Judkins sizes for smaller or larger aortas; Amplatz, XB type curves. Watch for “damping”; For separate ostia-separate catheters, larger for Cx, or counterclockwise rotation for LAD. Optimal Views LAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUS Left Main Coronary Artery
Slide 17-

Sternocostal Aspect
Slide 18-

Sternocostal Aspect
Slide 19-

Diaphragmatic Aspect
Slide 20-

Left Anterior Descending Artery Course down the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apex. Branches septals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus (courses like 1st diagonal). LAD Supplies anterolateral, apex and septum; ~45%-55% of left ventricle.
Slide 21-

Left Circumflex Artery Origin from distal LMCA. Course down distal left AV groove. Branches obtuse marginal, posterolaterals-supply posterolateral LV, anterolateral papillary muscle. SA node artery-38%. Supplies 15%-25% of LV, unless dominant (supplies 40-50% of LV).
Slide 22-

Left Coronary Artery AP (30)Caudal LMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO may be useful. AP (40)Cranial LMCA, LAD, diagonals, septals, distal Cx-may need RAO to separate LAD and Cx. (45)LAO (35) Cranial LMCA, LAD, diagonals, septals, and distal Cx. (45)LAO (30) Caudal LMCA, Cx,and prox LAD. Laterals (cranial, caudal) may be helpful. Optimal Views
Slide 23-

AP Caudal View of LCA LAD Circ
Slide 24-

Septal LAD Cx Diagonal AP Cranial View of LCA
Slide 25-

AP Cranial LCA Angiogram Septal Diagonals LAD LMCA Cx
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Circ Diagonal LAD LAO Cranial View of LCA
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LAO Caudal View of LCA Circ LAD Median Ramus
Slide 28-

Dominance: Definition 1: the coronary artery which reaches the crux of the heart and then gives off the PDA Definition 2: (Allows for codominance) the artery which gives off the PDA as well as a large posterolateral branch
Slide 29-

Left Dominant Circulation
Slide 30-

LCA Angiogram Distal LAD Prox LAD LM OM Distal Cx Occluded Median Ramus Dominant Cx AP Caudal
Slide 31-

LCA Angiogram-Dominant Cx LAO-Caudal Distal LAD LM Prox Cx LPDA Occluded Median Ramus Prox LAD
Slide 32-

The Coronary Arteries Are Complementary Large PDA Small LAD Huge Cx (posterolaterals)  Small RCA continuation in AV Groove Etc, etc, etc…..
Slide 33-

Wrap Around LAD
Slide 34-

Short LAD/Large RCA with Apical Extension
Slide 35-

BYPASS GRAFTS SVG Left coronary grafts generally arise from left side of the aorta. Best cannulated with Judkins’ Right, IMA, LCB or MP. Right sided grafts-arise from right side of the aorta-MP usually best. IMA don’t forget to check subclavians. All distal vessels must be accounted for; op notes and old films are extremely helpful.
Slide 36-

BYPASS GRAFTS Gastroepiploic visceral catheters (Cobra) enter celiac axis and then common hepatic artery and turn down into gastroduodenal. Use guidewire (Terumo) to cannulate the gastroepiploic for selective injections. Views multiple views to see ostia, shaft, and distal anastomosis. All distal vessels must be accounted for; op notes and old films are extremely helpful.
Slide 37-

SVG-OM-LAO Caudal Demonstrating Graft Ostium Ostium
Slide 38-

SVG-OM 1 AP Caudal Demonstrating Anastomosis SVG
Slide 39-

LIMA to LAD Origin from left subclavian (AP Cranial)
Slide 40-

LIMA to LAD Distal Anastomosis-AP Cranial LIMA LAD
Slide 41-

Left Subclavian Artery Stenosis
Slide 42-

RIMA to RCA
Slide 43-

RIMA to RCA
Slide 44-

Occluded Left-sided SVG
Slide 45-

Native LCA AP Caudal Stump of original SVG to OM 1
Slide 46-

SVG to OM Lesion 1 Lesion 2
Slide 47-

SVG to OM Slight change of view to demonstrate unequivocal severity of lesion Lesion 1 Lesion 2
Slide 48-

SVG to RCA Multipurpose Technique -LAO SVG
Slide 49-

AHA/ACC Lesion Classification TYPE B Tubular Eccentric Moderate tortuousity Moderately angulated (45-90) Irregular contour Moderate-heavy calcification Total occlusion (< 3 mos) Ostial Bifurcation Thrombus present TYPE A Discrete Concentric Readily Accessible Smooth Contour Little or no calcification Non-ostial No major side branch involved Absence of thrombus
Slide 50-

AHA/ACC Lesion Classification TYPE C Diffuse Excessive tortuousity Extremely angulated Total occlusion (> 3 mos) Inability to protect major side branch Degenerated SVG
Slide 51-

Ulcerated Plaque
Slide 52-

LCA AP Caudal Severe stenosis Distal LAD with slow flow
Slide 53-

Thrombus In LAD Post-NTG-Thrombus has migrated distally but still adherent Thrombus
Slide 54-

AP Cranial Thrombus In LAD Thrombus
Slide 55-

Embolization of Thrombus During Angiography Thrombus
Slide 56-

Calcified Native RCA (LAO Cranial) “Bone Island” Simulating Thrombus
Slide 57-

Myocardial Bridging Almost always LAD Occurs in 5-12% of patients Usually not hemodynamically significant Intramyocardial Segment
Slide 58-

Myocardial Bridging LCA-RAO Projection LAD Diastole LAD Systole
Slide 59-

Coronary Artery Fistula Origin50% RCA. Clinical Syndromes: CHF, endocarditis, ischemia, and rupture of aneurysmal fistula. 50% are asymptomatic. Drainage: RV-41%; RA-26%; PA-17%; LV-3%, and SVC-1%.
Slide 60-

Coronary Artery Fistula LCA-RAO Projection LAD to PA Fistula LAD PA Fistula
Slide 61-

Anomalous Origins of Coronary Arteries Most have severe ischemia early in life Only 25% survive to adulthood. Aortography shows large RCA with collaterals to LCA LCA from PA
Slide 62-

LCA from PA Large RCA Collaterals to LAD LAD arising from PA
Slide 63-

Anomalous Origin of LCA from the Right Sinus of Valsalva Rare Course relative to great vessels is variable and must be defined. If interarterial, surgical therapy is warranted.
Slide 64-

Anomalous Origin of RCA from Left Coronary Sinus Rare Arises anterior to the origin of the LCA Engage with Left Amplatz, or Left Judkins’ RCA runs an interarterial course Usually benign
Slide 65-

Normal and Anomalous Origins of the Coronary Arteries
Slide 66-

Benign Anomalies (0.5-1%) Left Circumflex from right Sinus of Valsalva Most common “benign” anomaly Circumflex courses behind aorta High Anterior Origin of RCA Above sinotubular ridge
Slide 67-

Anomalous Circumflex Artery
Slide 68-

Collateral Circulation-Development Preexisting-20 to 200 um First 24 hours-passive widening One day-3 weeks cellular proliferation, luminal diameter increases 10 fold. 3 weeks-6 months more cellular proliferation and development of extracellular matrix; channels may reach 1mm in caliber.
Slide 69-

Collateral Circulation-Development Ischemia and occlusion are the only factors currently recognized to result in significant collateralization. Usually need very high grade coronary artery occlusion for collaterals to be angiographically apparent.
Slide 70-

LCA -AP Cranial LAD Collateral to distal RCA
Slide 71-

Collateral “Connections” Occur where coronary arteries are in proximity Distal LADDistal PDA Cx AV grooveR AV groove SeptalSeptal MarginalMarginal DiagonalMarginal Also Bridging collaterals-associated with chronicity Kugel’s artery-prox RCA to distal RCA via AV groove Always look for conus to LAD collaterals when LAD is occluded and appears uncollateralized.
Slide 72-

Collateral Development After RCA Occlusion
Slide 73-

Collateral Pathways After LAD Occlusion
Slide 74-

Collateral Pathways After Circumflex Occlusion
Slide 75-

Classification of Collaterals 0 No epicardial filling at baseline or during balloon inflation 1 No epicardial filling at baseline with partial epicardial filling during balloon inflation 2 Partial baseline filling with partial or complete filling during balloon inflation 3 Complete epicardial filling at baseline Rentrop Grade “Recruitable collaterals”—collaterals which can become angiographically apparent only during occlusion, such as those observed during PTCA. Collaterals can be dilated by nitrates, B-adrenergic agents, NO and prostacyclin
Slide 76-

Recruitable Collaterals RCA Injection during LAD PTCA RCA angiogram demonstrates complete filling of LAD. No collaterals were apparent prior to balloon inflation.
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