Coronary Angiography and Cardiac Ventriculography

Robert N. Piana, MD

Aaron Kugelmass, MD

Mauro Moscucci, MD, MBA

INTRODUCTION

Diagnostic angiography begins with vascular access. Typically, this is achieved via the radial artery or common femoral artery, and less commonly through the brachial artery. The patient’s vascular anatomy should be fully understood and assessed before attempting arterial access. For femoral access, the assessment may include palpation of the femoral, dorsalis pedis, and posterior tibial pulses; auscultation for femoral bruits, inspection for surgical scars to suggest prior vascular surgery, and a review of records to understand prior vascular interventions or surgery. For radial access, the radial and ulnar pulses are assessed, dialysis fistulae are noted, and an Allen test is typically performed to ensure adequate hand perfusion should the radial artery occlusion occur (5% to 10% of cases). In addition to these measures, ultrasound is increasingly used to guide vascular access and femoral artery angiography should be performed as a routine in preparation for vascular closure devices deployment (FIGURE 10.1).

Catheter advancement from the access site to the heart requires careful attention to stenosis, tortuosity, calcification, and vascular anomalies. From the radial access, the operator utilizes both fluoroscopy and tactile feedback during catheter advancement to recognize a “radial loop,” accessory radial artery, or a true high origin of the radial artery from the upper segment of the brachial artery (FIGURE 10.2). Such anomalies may require crossing with coronary guide wires, downsizing of the catheter system, or potentially abandoning the approach for an alternative access. Exquisite attention to these vascular anomalies can help prevent painful severe radial artery spasm, dissection, or even perforation. As radial patients are generally anticoagulated, such complications can result in significant hematoma or even compartment syndromes.

Particularly in elderly patients, the right subclavian and brachiocephalic arteries may be quite tortuous, in some cases forming nearly a 360° loop. A hydrophilic guide wire can generally be negotiated successfully through such a loop. Deep inspiration can then help reduce the loop, allowing the catheter to be advanced to the ascending aorta (FIGURE 10.3).

FIGURE 10.1 Angiography performed in RAO projection through the inner dilator of a micropuncture sheath (double white arrows) in the right common femoral artery. Also noted are the superficial epigastric artery (single white arrow), profunda femoral artery (single black arrow), and superficial femoral artery (double black arrows). Sheath placement above the femoral bifurcation and below the inguinal ligament reduces the likelihood of retroperitoneal bleeding from a high puncture, pseudoaneurysm from a low puncture in the profunda or superficial femoral artery and optimizes the opportunity to utilize a femoral closure device.

FIGURE 10.2 Radial artery loop.

FIGURE 10.3 A, Tiger 4 Catheter with tip in proximal descending aorta. Note the loop in the right subclavian-innominate artery. B, Catheter withdrawn somewhat in attempt to access ascending aorta (AA), but loop becomes even more pronounced. C, Careful torqueing over the wire points catheter tip toward the AA. D, Deep inspiration reduces the vascular loop and allows the guide wire to be passed into the AA over which the catheter is advanced. E, Catheter now in the aortic root.

CORONARY ANGIOGRAPHIC VIEWS

Coronary angiography utilizes a combination of right to left and cranial to caudal angulations to optimize imaging of the coronary arteries. Specific views optimize visualization of specific coronary artery segments (FIGURE 10.4).

Body habitus may limit angulation of the imaging system, and sternal wires, pacemakers/defibrillators, and other implanted devices can obscure lesions. Vessel overlap can be challenging as well. Integrating information from fluoroscopy to assess for calcification and prior stents, multiple angiographic views, the pattern and speed of contrast flow and washout, and the pressure waveforms from the catheter tip is essential to maximizing the coronary assessment (FIGURES 10.5, 10.6, 10.7, 10.8, 10.9 and 10.10).

FIGURE 10.4 A, RAO Caudal projection of the left coronary artery. This view is used to visualize the left main (LM), proximal left anterior descending (LAD), and proximal circumflex (LCX) arteries. Note brisk contrast reflux from the LM, reflecting adequate contrast injection to assess for an ostial lesion. A broad flush of contrast reflux and the absence of damping/ventricularization of the catheter tip pressure both help in excluding a significant ostial left main stenosis. A large branching first diagonal artery is noted (D1). B, RAO Cranial projection of the left coronary artery. This view is used to visualize the mid- and distal LAD without overlap of septal or diagonal branches. In this case, however, the large branching D1 does overlap the mid-LAD. Steeper RAO angulation may eliminate this, or this segment may be better seen in LAO cranial (4C). C, LAO Cranial projection of the left coronary artery. This view is used to visualize the mid- and distal LAD in an orthogonal projection. Note that the mid-LAD just after the first septal (S1), which was obscured by D1 in the RAO Cranial (4B), is now clearly seen without obstruction. D, LAO Caudal projection of the left coronary artery. This view is used to visualize the LM and proximal LCX. E, LAO cranial projection of the right coronary artery RCA. This view is used to visualize the distal RCA and its bifurcation into the posterior descending (PDA) and posterolateral arteries. Note pacemaker wire that can obscure lesion assessment. In this example, angulation is adjusted to avoid overlap with the PDA origin. F, RAO projection of the right coronary artery RCA. This view is used to visualize midportion of the RCA and the body of the PDA, and in some cases it can demonstrate the origin of the PDA well, as in this example.

FIGURE 10.5 A, RAO Caudal projection of the left coronary artery. Distal LM lesion partially obscured by a sternal wire. B, LAO Caudal projection of the left coronary artery. Even at 40 LAO/40 Caudal the distal left main cannot be visualized owing to overlap. C, Shallow LAO with shallow cranial elongates the left main and allows visualization of a napkin ring distal left main lesion.

FIGURE 10.6 A, Left panel shows shallow LAO Caudal fluoroscopic view of the left main. A prior stent in the very proximal LAD appears to extent back into the distal LM. Right panel shows distal left main stenosis at the proximal stent edge. Note the narrow reflux of contrast from the ostial LM, suggesting ostial LM disease as well. In fact there was ventricularization of catheter pressure. B, Catheter pulled back slightly reveals ostial LM lesion. C, RAO Caudal projection of the left coronary artery. Distal LM lesion clearly seen with a narrow jet of contrast reflux, consistent with the ostial left main stenosis.

FIGURE 10.7 Two views of an ostial left main stenosis. Minimal contrast reflux is noted. There was damping of catheter pressure with engagement of the left main.

FIGURE 10.8 A, Left panel shows (arrow) distal LM tapering and severe ostial LAD lesion. Right panel shows quantitative angiography assessment of distal LM stenosis. B, Steep LAO Caudal projection now shows the ostial LAD stenosis (arrow) is critical.

FIGURE 10.9 A, Left panel: LAO view of the RCA shows moderate diffuse disease. A “shepherd’s staff” anatomy of the proximal RCA is noted. In the RAO projection a critical mid-RCA lesion (arrow) is now revealed (right panel). B, Left panel: Diffuse calcification (arrows) is noted in the proximal RCA. Along with the “shepherd’s staff” anatomy of the proximal RCA, this information suggests stent delivery may be challenging. Ablative procedures such as rotational atherectomy would be considered. Right panel: After unsuccessful attempts with other guides, a 6 French 3DRC guide and a Guideliner (arrows) were used to deliver a balloon to the lesion site. Adequate balloon expansion is seen indicating this is a dilatable lesion. C, Left panel: Guideliner (black arrow) positioned in the proximal RCA provides additional support to the guide for successful stent delivery (white arrow). Right panel: mid-RCA lesion is now successfully stented.

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