Coronary angiography standard views

Coronary Angiography
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General Principles Overview Historical Perspective Contraindications Appropriate Use Criteria for Revascularization Complications Technique Film Quality
Anatomy & Projection Angles
Normal Anatomy Coronary arteries Dominance Right System Left System Left Main Left Anterior Descending Circumflex Median Ramus
Anatomic Variants Separate Ostia Anomalous Origins Case Example Fistula
Projection Angles Standard Views Left Coronary Artery Right Coronary Artery
Epicardial Flow & Myocardial Perfusion
Epicardial Flow TIMI Frame Count TIMI Flow Grade TIMI Grade 0 Flow TIMI Grade 1 Flow TIMI Grade 2 Flow TIMI Grade 3 Flow TIMI Grade 4 Flow Pulsatile Flow Deceleration
Myocardial Perfusion TIMI Myocardial Perfusion Grade TMP Grade 0 TMP Grade 0.5 TMP Grade 1 TMP Grade 2 TMP Grade 3
Lesion Complexity
ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis
Preprocedural Lesion Morphology Eccentricity Irregularity Ulceration Intimal Flap Aneurysm Sawtooth Pattern Length Ostial location Angulation Proximal tortuosity Degenerated SVG Calcification Total occlusion Coronary Artery Thrombus TIMI Thrombus Grade TIMI Thrombus Grade 0 TIMI Thrombus Grade 1 TIMI Thrombus Grade 2 TIMI Thrombus Grade 3 TIMI Thrombus Grade 4 TIMI Thrombus Grade 5 TIMI Thrombus Grade 6
Lesion Morphology Quantitative Coronary Angiography Definitions of Preprocedural Lesion Morphology Irregular Lesion Disease Extent Arterial Foreshortening Infarct Related Artery Restenosis Degenerated SVG Collaterals Aneurysm Bifurcation Trifurcation Ulceration
Left ventriculography
Technique Quantification of LV Function Quantification of Mitral Regurgitation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Standard Angiographic Views

Rotation describes the position of the image intensifier around the longitudinal axis of the patient. LAO refers to rotating the camera to the patient's left (catheter and spine will be on the right side of the image), RAO to the patient's right (catheter and spine on the left side of the image). Angulation describes the position of the image intensifier in the short axis of the patient. Camera can pivit toward (cranial) or away (caudal) from the patient's head. Diagram

For the beginner angiographer the anatomic landmarks formed by the spine, catheter and diaphragm provide information to discern which tomographic view from which the image is obtained. In the LAO view (figure 1) the catheter and spine are seen on the right side of the image, while in the RAO (figure 2) they are found on the left. PA imaging (figure 3) places these landmarks in the center of the image. Cranial angulation can usually be distinguished from caudal angulation by the presence of the diaphragm. For cranial imaging, the patient should be asked to inspire to remove the diaphragmatic shadow from the image.

Post-surgical Views

• Left Lateral; LIMA (body)
• Right Cranial; LIMA to mid LAD
• Right Caudal; LIMA to distal LAD
• Left Lateral; LIMA to distal LAD
• Right Cranial; LIMA to diagonal arteries
• Left Lateral SVG to LAD

Figure 1

Figure 2

Figure 3

Left Coronary Artery

The left main coronary artery gives rise to the left anterior descending artery and the left circumflex coronary artery. Complete visualization of these arteries and their branches requires care and rigor to ensure complete anatomical documentation. Often bifurcations and vessel foreshortening and overlap cause errors in stenosis estimation. There are no steadfast rules in which tomographic views are most useful. Generally, for circumflex and proximal epicardial visualization the caudal views are most useful. For LAD and LAD/diagonal bifurcation visualization the cranial views are most useful. Overall, if there is not a significant limitation on contrast utilization, standard 'around the world' angiography using a selection of the following angiographic views will document left coronary anatomy.

RAO 20 - Caudal 20

RAO Caudal

RAO Cranial

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AP 0 - Caudal 30

PA Caudal

LAO 50 - Caudal 30

LAO Caudal

LAO 50 - Cranial 30

LAO Cranial

AP 0 - Cranial 40

PA Cranial

Right Coronary Artery

LAO View

Initial angiographic imaging of the RCA in this view (LAO 30) gives the best view of significant ostial and proximal RCA disease.

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RAO View

The mid RCA is best visualized in the straight RAO 30 position.

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AP 0 Cranial 30 View

The bifurcation of the distal RCA and rPDA is best seen in the AP 0 Cranial 30 view with a small breath in.

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