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Cardiac

Catheterization
and
Coronary Angiography
Andre Tritansa Faizal
Nurnajmia Curie Proklamatina

Resource Person: dr. Doni Firman, SpJP (K)

History

Eric J. Topol (ed). Textbook of Cardiovascular Medicine, 3rd ed. 2007


www.heartviews.org

Definition
Cardiac Catheterization
A procedure use catheter that inserted to
measure pressures in the heart chambers, to
determine cardiac output and vascular
resistances and to inject radiopaque material to
examine heart structures and blood flow

Pathophysiology of Heart Lily 6th Ed 2015

Indication of Diagnostic
Cardiac Catheterization
to confirm or exclude the presence of a
condition already suspected from the history,
physical examination, or noninvasive
evaluation;
to clarify a confusing or obscure clinical picture
in a patient whose clinical findings and
noninvasive data are inconclusive;
to confirm the suspected abnormality and to
exclude associated abnormalities that may
require a surgeon's attention in patients for
whom corrective surgery is contemplated
Eric J. Topol (ed). Textbook of Cardiovascular Medicine, 3rd
ed. 2007

Relative Contraindication to
Diagnostic Cardiac
Catheterization

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th
Edition, 2015.

Technical Aspect of Cardiac


Catheterization
50% outpatient procedure
Indication for postprocedural hospitalization:
Hematoma formation
Diagnosis post procedure eg. Severe LM,
proximal 3VD
Uncompensated HF, unstable ischemic
symptoms, severe AS with LV dysfunction,
renal insufficiency, continuous anticoagulation

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Preparation of the Patient


Explain the procedure, risk and benefit
Pre-cath evaluation:history, physical exam, ECG,
CBC, electrolyte, creatinin, blood glucose, PT
with INR
Fasting for 6 hours
Premedication: sedation, antihistamine
Discontinue oral anticouagulant 3 days before,
INR < 1.8
Discontinue metformin until stable renal function
for 48 hrs
Hydration pre and post procedure
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Right Heart Catetherization


Measurement and analysis of:
Right atrium
Right ventricle
Pulmonary artery, pulmonary capillary wedge
pressure
Cardiac output
screening of intracardiac shunts
Performed antegrade through IVC or SVC
Entry via femoral, internal jugular, subclavian,
antecubital vein
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Balloon
Flotation
Catetherizatio
n

From Baim DS, Grossman W: Percutaneous approach, including transseptal and apical puncture.
In Baim DS, Grossman W : Cardiac Catheterization, Angiography, and Intervention. 7th ed. Philadelphia, Lea &
Febiger, 2006, p 86.)

Left Heart Catetherization


The Judkins
Technique

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Left Heart Catetherization


Modified Seldinger Technique

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Hemodynamic Data
Pressure measurement
Measurement of Flow
Determination of vascular resistance
Ohms Law:

Q= P/R

Normal Right and Left Heart Pressure Recorded


from Fluid Filled Catheter in Human

Pepine C,Hill JA, Lambert CR (eds). Diagnostic and Therapeutics Cardiac Catheterization.3rd ed. 1998

Normal
Pressure

Bonow RO, et al (eds).


Braunwald Heart Disease: A
Textbook of Cardiovascular
medicine. 10th Edition, 2015.

Cardiac Output Measurement


Method
Fick
Thermodilution

Most reliable
Low cardiac
output
High cardiac
output

Least reliable
High cardiac output
Pulmonic regurgitation
Tricuspid regurgitation
Intracardiac shunting

Angiographic

Normal-shaped
ventricle

Extensive segmental
wall motion
abnormalities
arrhytmia
Aortic regurgitation
Mitral regurgitation

Eric J. Topol (ed). Textbook of Cardiovascular Medicine, 3rd ed. 2007

Fick method

Thermodilutio
n

Bonow RO, et al (eds). Braunwald Heart


Disease: A Textbook of Cardiovascular
medicine. 10th Edition, 2015.

Shunt
Quantification
Flamm formula

Flow ratio

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Systemic Vascular
Resistance

Pulmonal Vascular
Resistance

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Physiologic & Pharmacologic


Maneuvers
Dynamic exercise
Pacing Tachycardia
Physiologic stress The Valsalva maneuver,
Kussmaul sign
Dobutamine infusion indicated in low flow,
low gradient AS
Inhaled NO pulmonary hypertension
Sodium nitroprussidepredict good clinical
outcome in dilated cardiomyopathy and MR

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Adjunctive Diagnostic Technique


LV Electromechanical Mapping
Distinguish viable and non viable myocardium,
ischemic and non ischemic myocardium
Predict recovery of function after
revascularization
Guiding stem cell injection
Intracardiac Echocardiography (ICE)
Provide imaging of interatrial or interventricular
septum and left heart structures
Guidance of percutaneous ASD and PVO closure
Localization of fossa ovalis for transseptal
puncture

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Coronary Angiography

Outline
Overview
Indications and Contraindications
Complications
Technique
Pitfalls

Overview
Coronary angiography: imaging technique that uses Xrays to take coronary vessels pictures
Remains standard to identify presence/absence of
arterial narrowings related to CAD
Most reliable anatomic information for determining
appropriateness of medical therapy
1st performed by Mason Sones (1959), methods have
improved substantially since then

How is Coronary Angiography Done?

http://patient.info/health/coronary-angiography

Coronary Angiography Principle


Radiation from x-ray tube is
attenuated as passes
through body, detected by
image intensifier
Contrast injected to
coronaries enhances x-rays
absorption sharp contrast
with tissues
X-ray shadow converted to
visible light image, displayed
on fluoroscopic monitors,
stored on digital storage
system
Flat-panel detectors replace
image intensifiers (reduce
radiation exposure, enhance
image quality)

Bonow RO, et al. Braunwald Heart Disease. 9th Edition,


2012.

Radiation Exposure (1)


2 forms of radiation injury:
Deterministic injury result in cell
death and organ dysfunction
(dose-dependent, most
commonly result in skin injury)
Stochastic injury result in
genetic mutations (not dosedependent)

Radiation dose is measured


as:
Total radiation exposure,
determined from x-ray tube
output, expressed as dose-area
product (DAP)
Interventional reference point
(IRP) dose, est. radiation dose to
patients skin

Kern M. Do You Know Your Radiation Dose During Your Cath?


Cath Lab Digest. Volume 19 - Issue 6 - June 2011

Radiation Exposure (2)

Kern M. Do You Know Your Radiation Dose During Your Cath? Cath Lab Digest. Volume 19 - Issue 6 - June 2011

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Contraindications
No absolute contraindications
Relative contraindications:

unexplained fever
untreated infection
severe anemia or active bleeding
critical electrolyte imbalance
uncontrolled systemic hypertension
digitalis toxicity
ongoing stroke
acute renal failure
decompensated heart failure
severe intrinsic or iatrogenic coagulopathy (elevated INR)
active endocarditis

Complications

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Technique of Coronary
Angiography

Patient Preparation
Lab exam <2 weeks prior: Hb, platelet, electrolyte,
creatinine, PT (warfarin, liver disease, coagulopathy)
Continue aspirin, UFH, LMWH, GP IIb/IIIa inhibitor
Discontinue warfarin (3 days prior), target INR 1.8
(femoral), 2.2 (radial), may treat with UFH/LMWH
Discontinue dabigatran 24 hrs prior (GFR >50 mL/min),
48 hrs prior (GFR 30-50 mL/min)
Discontinue metformin prior until renal function
normalized post procedure

Vascular Access (1)


Depends on operator-patient
preferences, anticoagulation status,
peripheral vascular disease
Femoral artery approach
Most commonly used
Puncture site distal to inguinal
ligament, prox to bifurcation of
superficial & profunda femoral artery
Bed rest for 1-2 hours after removal of
4-5F sheath and 2-4 hours of 6-8F
sheath, longer if there is higher risk of
bleeding

Davidson CJ, Bonow RO. Cardiac catheterization.


In: Braunwalds Heart Disease 10th edition. 2015

Brachial artery approach

Preferred to femoral in presence of


severe peripheral vascular disease and
morbid obesity
Easily accommodates 8F (1F = 0.33mm diameter) sheath
Risk of blood supply compromise to
forearm and hand in event of a
vascular complication
http://www.myheart.com.pk/angiography/

Vascular Access (2)

Radial artery approach

Preferred to brachial due to ease of


catheter entry & removal; dual blood
supply to hand
UFH (up to 5000 U)/bivalirudin for
brachial & radial artery approaches
Hydrophilic sheath and I.A. verapamil
& NTG reduce spasm
Factors assoc. with unsuccessfulness:
high-bifurcation radial origin, full radial
loop, extreme radial artery tortuosity
Immediate ambulation; compared to
femoral: lower cost, improve coronary
visualization, reduce bleeding
complications
Generally accommodate 4-6F
catheters

http://www.premierhealthspecialists.or
g/

Allen test prior to procedure (ulnar arterial flow


adequacy)
Watson S, Gorski KA. Invasive Cardiology: A Manual
Cath Lab Personnel. 3rd Edition. 2011.

Catheters
Polyethylene/polyurethane with fine wire braid within wall
to allow advancement and directional control and prevent
kinking
Outer diameter size 4-8F (5-6F most common for diagnostic
arteriography)

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Judkins Catheters

JL catheter is preshaped to
allow entry into LCA from
femoral with minimal
manipulation (JL 4.0); for
left/right brachial/radial
artery 0.5 cm less curvature
than for femoral is better
suited
JR catheter is preshaped to
permit entry into RCA with
small amount of rotational
(clock-wise) manipulation
from any vascular approach
Catheter selection is based
on habitus and aortic root
size

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Amplatz Catheters
Femoral or brachial
approach
Excellent alternative in
cases in which Judkins
catheter is not
appropriately shaped to
enter coronary arteries
Amplatz L-1 or L-2 may be
used from right brachial or
radial approach
Modified Amplatz right
catheter (AR-1 or AR-2) can
be used for engagement of
a horizontal or upward
takeoff RCA or SVG
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Other Catheters
IMA left catheter with
angulated tip allows
engagement of IMA or
upward takeoff RCA
Catheter shapes that
permit engagement of
SVGs include
multipurpose catheter
and Judkins right,
modified Amplatz right,
and hockey stick
catheters

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Drug Used (1)


Analgesics

Conscious sedation (respond to verbal commands; maintain


patent airway)
Diazepam 2.5-10 mg orally, diphenhydramine, 25-50 mg orally, 1
hour prior
I.V. midazolam 0.5-2 mg, fentanyl 25-50 g for sedation during
procedure

Anticoagulants

IV UFH no longer routinely required


Increased thromboembolic risk (severe AS, critical PAD, arterial
atheroembolism, undergoing >1-2 min use of guidewires in
central circulation) may be given I.V. UFH 2000-5000 U
Brachial/radial artery catheterization should receive systemic
UFH/bivalirudin
Frequent catheters heparinized saline flush prevent microthrombi
formation within catheter tip
Continuous flush through arterial access sheath may lower distal
thromboembolism
Anticoagulant effect of UFH can be reversed with protamine 1 mg
for every 100 U of heparin

Drug Used (2)

Treatment of Periprocedural Ischemia


Angina induced by tachycardia, hypertension, contrast agents,
microembolization, coronary spasm/enhanced vasomotor tone,
or dynamic platelet aggregation
NTG SL (0.3 mg), I.C. (50-200 g), or I.V. (10-25 g/min) in SBP
>100 mm Hg
No contraindication to BB: I.V. metoprolol 2.5-5.0
mg/propranolol 1-4 mg
IAB counterpulsation as adjunctive in coronary ischemia and
left main CAD, cardiogenic shock, or refractory pulmonary
edema

Contrast Agent (1)


May produce adverse hemodynamic, electrophysiologic,
renal effects
Side effects frequency varies depends on ionic content,
osmolality, viscosity
Ionic agents:

Dissociate into cations & iodine-containing anions


High serum osm (>1500 mOsm) hypertonic
SB, heart block, QT & QRS prolongation, ST depression, giant
T inv, decreased LV contractility, decreased SBP, increased
LVEDP; calcium-chelating properties also contribute to
cardiac effects

Non ionic agents:

Do not ionize in solution, more iodine-containing particles


per milliliter of contrast material
Lower osmolality (<850 mOsm), do not chelate calcium,
fewer side effects
Side effects relate in part to hyperosmolality hot flush,
nausea, vomit, arrhythmia

Contrast Agent (2)


Contrast-Induced Nephropathy

Contrast Reaction Prophylaxis

Worsening renal fx (10-20%),


esp. previous renal insuff, DM,
dehydration, HF, large contrast
volume, 48 hrs exposure to
contrast highest risk: DM,
eGFR <60 mL/min
Fluid administration I.V.
saline/sodium bicarbonate 1-1.5
mL/kg/min for 3-12 hours before
procedure and 6-12 hours after
procedure

Rx to contrast agents:
1. Mild (9%)grade I: single episode of
emesis/nausea/sneezing/vertigo
2. Moderate (9%) grade II: hives or
multiple episodes of
emesis/fevers/chills
3. Severe (0.2-1.6%) grade III: shock,
bronchospasm,
laryngospasm/edema, unconscious,
hypotension, hypertension,
arrhythmia, angioedema, pulmonary
edema
Prophylactic H1 & H2 receptor
blocker (diphenhydramine 50 mg,
cimetidine 300 mg) and aspirin
Severe previous rx: prednisone 60
mg night before & 2 hours prior

Anatomy and Variations of Coronary


Arteries
Major epicardial and 2nd-3rd order branches can be
visualized by coronary arteriography
Smaller intramyocardial branches are not seen due to
their size, cardiac motion, limitations in angiographic
systems resolution
Smaller vessels perfusion quantitatively assessed by
myocardial blush score prognostic in STEMI and
those undergoing PCI

Smithuis R, Willems T. Coronary


anatomy and anomalies. Radiology
Department of the Rijnland Hospital
and the University Medical Center
Groningen.
http://www.radiologyassistant.nl/

Arterial Nomenclature and Extent of


Disease
Major coronary arteries : LAD, LCx, RCA (dominance
defined by presence of posterior descending and
adjacent posterolateral branch)
CAD is defined as 50% diameter stenosis in 1 of
these vessels
Subcritical stenoses <50% are characterized as
nonobstructive CAD
Obstructive CAD is classified as one-, two-, or threevessel disease

BARI-CASS Coronary Artery


Nomenclature

Major determinants of 6-year outcome: number of diseased vessels,


number of diseased proximal segments, and global LV function
accounted for 80% of the prognostic information

Alderman, et al. Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the bypass
angioplasty revascularization investigation (BARI). J Am Coll Cardiol. 2004;44(4):766-774.

Syntax Score

http://www.medscape.com/

Angiographic Projections
Heart is oriented obliquely in thoracic cavity RAO and
LAO projections to furnish true posteroanterior and lateral
views of heart, limited by vessel foreshortening &
branches superimposition
Simultaneous x-ray beam rotation in sagittal plane
provides better view:
Cranial view: image detector is tilted toward patients head
Caudal view : image detector is tilted down toward patients feet

Optimal angiographic projection depends on body habitus,


variation in coronary anatomy, location of lesion
Recommendation:
Both LAO and RAO projections with both cranial and caudal
angulation
At least two views of LCA and RCA

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Left Coronary Artery (1)


LMCA
Arises from superior portion
of left aortic sinus, just below
sinotubular ridge of aorta
Diameter 3-6 mm, length 1015 mm
Courses behind RVOT and
bifurcates into LAD and LCx
Rarely absent LAD and
LCx have separate ostia
Best visualized: AP projection
0-20caudal angulation
Should view several
projections with vessel off
the spine to exclude LMCA
stenosis

Popma JJ, et al. Coronoary ateriography and intracoronary


imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Left Coronary Artery (2)


LAD

Courses along epicardial


surface of anterior IV
groove toward apex
RAO projection: extends
along heart anterior
aspect
LAO projection: passes
down cardiac midline,
between RV & LV
Major branches:

Septal branches arise at


approximately 90
angles and pass into
IVS, varying in size,
number, and distribution
Diagonal branches pass
over anterolateral
aspect of heart

- Best angiographic
projections for LAD :

LAO cranial: midportion


of LAD and separates
diagonal and septal
branches
RAO cranial: proximal,
middle, distal segments
of LAD and separates
diagonal branches
superiorly and septal
branches inferiorly
AP cranial (20-40):
midportion of LAD,
separating it from
diagonal and septal
branches

Left Coronary Artery (3)

LCx
Courses within posterior (left) AV groove toward inferior IV groove
Supplying left PDA from distal continuation of LCx (15%)
Remaining patients, distal LCx varies in size and length,
depending on number of posterolateral branches supplied by
distal RCA
Gives off 1-3 large obtuse marginal branches as it passes down
AV groove principal branches of LCx, supply LV lateral free wall
Gives rise to 1-2 LA Cx branches supply lateral and posterior
LA
RAO and LAO caudal: prox & mid LCx and obtuse marginal
branches
AP or 5-15 RAO caudal: origins of obtuse marginal branches
LAO cranial: left PDA if LCA is dominant

Right Coronary Artery (1)


Originates from right anterior aortic sinus, inferior to
origin of LCA, passes along right AV groove toward crux
First branch conus artery, arises at RCA ostium or
within first few mm of RCA (50% of patients). Remaining
patients, arises from separate ostium in right aortic sinus
just above RCA ostium
Second branch sinoatrial node artery, arises from RCA
in <60% patients, LCx artery <40%, and both arteries
with a dual blood supply in remaining cases
Midportion of RCA usually gives rise to one /several
medium-sized acute marginal branches supply anterior
wall of RV and may provide collateral circulation in LAD
occlusion

Right Coronary Artery (2)


RCA terminates in PDA and one/more RPL branches
RCA traverses both AV and IV grooves multiple projections
are needed to visualize each segment
LAO cranial/caudal angulation: ostium of RCA
Left lateral view: ostium of RCA in difficult cases, identified by
reflux of contrast material from RCA, which also delineates
aortic root with swirling of contrast in ostium region
LAO cranial/caudal: proximal RCA, but markedly foreshortened
in RAO projections
LAO cranial, RAO, and left lateral projections: mid- portion of
RCA
LAO cranial or AP cranial: Origin of PDA, posterolateral
branches
AP cranial or RAO projection: midportion of PDA

RCA Dominance
Dominant (85%)

Supply PDA and at least one


posterolateral branch (right dominant)
PDA courses in inferior IV groove,
gives rise to small inferior septal
branches, which pass upward to
supply lower portion of IVS and
interdigitate with superior septal
branches passing down from LAD
After giving rise to PDA, RCA continues
beyond crux cordis as right posterior
AV branch along distal portion of
posterior (left) AV groove, terminating
in one or several posterolateral
branches supplying LV diaphragmatic
surface

Nondominant/Left dominant (15%)

One half have left PDA and left


posterolateral branches that are
provided by distal LCx
RCA is very small, terminates before
reaching crux, does not supply LV

Codominant/Balanced (remaining)

RCA gives rise to PDA, LCx provide all


of posterolateral branches

http://www.syntaxscore.com/

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Standardized Projection Acquisition


Each coronary artery should be visualized using different
projections that minimize vessel foreshortening and overlap
AP view + shallow caudal angulation often obtained first to
evaluate LMCA
Other important views:

LAO cranial (middle and distal LAD), leftward positioning of image


intensifier should be sufficient to allow separation of LAD, diagonal,
and septal branch
LAO caudal (LMCA, origin of LAD, and proximal LCx)
RAO caudal (LCx and marginal branches)
Shallow RAO/AP cranial (mid and distal LAD)

RCA at least two views (LAO & RAO):

LAO cranial (RCA and origin of PDA and posterolateral branches)


RAO (mid-RCA and proximal, middle, and distal termination of PDA)
AP cranial may be useful (distal termination of RCA)
Left lateral (ostium of RCA and midportion of RCA with separation of
RCA and its RV branches)

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Congenital Abnormalities of
Coronary Circulation
Divided into those that
cause and do not cause
myocardial ischemia
Malignant features of
anomalous coronaries:
slitlike ostium, acute
angle of takeoff,
intramural course,
significant compression
between aorta and
pulmonary trunk

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Myocardial Bridging
3 major coronary arteries

course along epicardial surface


Occasionally, short segments
descend into myocardium for
variable distance myocardial
bridging (5-12%), usually LAD
Bridge of myofibers passes
over involved segment of LAD
each systolic contraction
cause narrowing of artery
Angiography: bridged segment
is of normal caliber during
diastole, abruptly narrows with
each systole

No hemodynamic significance
in most cases, may be
associated with angina,
arrhythmia, depressed LV
function, myocardial stunning,
early death after cardiac
transplantation, SCD

Smithuis R, Willems T. Coronary anatomy and anomalies.


Radiology Department of the Rijnland Hospitaland the Unive
Medical Center Groningen. http://www.radiologyassistant.nl/

Assessing Lesion
Complexity
Heterogeneity of
composition, distribution,
and location of plaque
results in unique patterns
of stenosis morphology

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015

Quantitative Angiography
Quantitative analysis of digital angiograms:
Image calibration:
Using contrast-filled diagnostic or guiding catheter as a scaling device,
yielding a calibration factor in millimeters per pixel

Arterial contour detection (mapping):


Drawing center line through segment of interest
Linear density profiles are constructed perpendicular to center line,
and weighted average of 1st and 2nd derivative functions is used to
define catheter or arterial edges
Individual edge points are connected using automated algorithm, and
outliers are discarded and edges are smoothed
The automated algorithm is applied to selected segment, absolute
coronary dimensions & percent diameter stenosis are obtained

Pitfalls of Coronary Angiongraphy


Coronary angiography limitations:
substantial interobserver variability
lack of correlation with functional measures with intermediate
(40% to 70%) stenoses
inability to identify vulnerable plaque lesions that may be
predisposed to rupture

Technical factors can be mitigated at time of image


acquisition to improve interpretations:

Inadequate vessel opacification


Eccentric stenoses
Superimposition of branches
Microchannel recanalization

Inadequate Vessel Opacification


Causes:

Increased native coronary flow in LVH, aortic


insufficiency, or anemia
Competitive filling from collateral branches or
bypass graft conduits
Catheter positioning that is not in line with
coronary ostium
Use of a smaller (4F) injection catheter
Dislodgment of diagnostic catheter during injection
of contrast agent

Overcome by:

Forceful injection of contrast agent so long as


catheter tip position and pressure recording confirm
safety of such a maneuver
Switching to angioplasty-guiding catheter (soft,
short tip, larger lumen than diagnostic catheter)

Eccentric Stenoses
Hemodynamic significance is dependent on percentage
area stenosis, not worst percentage diameter
stenosis
Difficulty in ascertaining hemodynamic significance of
eccentric and bandlike lesions measurement of
fractional flow reserve (FFR) with micromanometer-tip
guidewire across abnormal region during I.V. adenosine

Superimposition of Branches
Common LAD & parallel diagonal branches
May occur ostium of obtuse marginal branch of LCx
& origin of RV branch of RCA
Obtain sufficient angulation to identify exact anatomy
at origin of side branch
Cranial projections for LAD
Caudal projections for LCx
Left lateral projection for RCA

Microchannel Recanalization
Angiography lacks resolution to differentiate 90%
stenoses from recanalized total occlusions with
microchannels & bridging collaterals
Recanalization development of multiple tortuous
channels small, close to one another, impression of
single, slightly irregular channel
Wire crossing may not be possible in some cases unless
advanced wire techniques are used

Thank You