Anatomy of the coronary

circulation
&
Angiographic VISUALIZATION
Dr Sandeep Mohanan
Department of Cardiology
Calicut Medical College
1/10/12


OUTLINE
Coronary arterial anatomy

Variations in coronary circulation

Coronary venous anatomy

Angiographic views of coronary arteries
Coronary arterial anatomy
1
st
anatomical drawings- Leonardo da Vinci
Oblique inverted crown

The coronary arteries and their major
branches are sub-epicardially located
Epicardial Vessel
Subepicardium
Subendocardium
Myocardium
Pericardium
(Epicardium)
LCA ostium ~ 4mm
RCA ostium~ 3.2mm
The LEIDEN convention
Each artery arises from respective aortic sinuses
- Right coronary sinus(anterior)
- Left coronary sinus(left posterior)
- Non-coronary sinus(right posterior)
1R2LCx
pattern
Right coronary artery
~ 9.8cm
1)Conus artery/ Infundibular/ Third coronary/ Adipose
/Arteria of Vieussens
- Separate ostium in 23% - 51%
- Circle of Vieussens
Right coronary artery
2) Atrial branches of the RCA
- < 1mm
- SA nodal artery ( Ramus crista terminalis) 55-65%

Right coronary artery
3) Right ventricular branches
- Acute right marginal artery
- Ramus crista supraterminalis (Superior septal artery)
12 -20% , males
Right coronary artery
4) Posterior descending artery
- Dominance
- Posterior septal branches - < 15mm
5) AV nodal artery
- 80 -90%
Right coronary artery
6) Postero-lateral branches to the LV

- Inferior wall of the LV
Clinical division of the RCA
Proximal - Ostium to 1
st
main RV branch
Mid - 1
st
RV branch to acute marginal branch
Distal - acute margin to the crux
Left coronary artery
LMCA
- 10-15mm(upto 30mm) length & 3-6mm(upto 10mm
diameter)
- Trifurcates in 1/3rd : Ramus intermedius/ median artery/ left
diagonal artery/straight LV artery
- Rare variations absent LMCA/ pentafurcation

Left anterior descending artery

- ~ 14.7 cm ; Type I (22%) , Type II & Type III
- 2-9 diagonal branches
- 90deg bend after turning around P. conus as it gives off 2
nd

diagonal branch
- Right ventricular branches( left conal/pre-infundibular A)
- ~ 10 septal perforating branches (40-80mm X 0.5-1.2mm)
anchors the LAD



LAD(contd)
- 1st proximal septal A is prominent (His Bundle and LBB)
- Myocardial bridging 0.5-1.6% overall (28% in children)
- Rarely dual LADs



Clinical division of the LAD
Proximal - Ostium to 1
st
major septal perforator
Mid - 1
st
perforator to D2 (90 degree angle)
Distal - D2 to end
Left circumflex artery
- ~9.3 cm long ; 1.5 -5mm
- Left atrial branches
- Kugels artery (Arteria anastomotica auricularis magna)
- LV branches are called the Obtuse marginal arteries
Clinical division of the LCX
Proximal - Ostium to 1
st
major obtuse marginal branch
Mid - OM1 to OM2
Distal - OM2 to end
Coronary segment classification
system
CASS investigators 27 segments
BARI 29 segments ( ramus intermedius and
3
rd
diagonal branch)

- Obstructive CAD : > 50% stenosis
Dominance
A misnomer
giving rise to PDA, at least 1 PLV & AV nodal A
(BARI classification)
- 85% right dominant
- 8% left dominant
- 7% co-dominant
(70%/ 10%/ 20% Hursts THE HEART)

Left dominance is 25-30% in Bi-AoV
Gensini GG. Coronary Arteriography. Mount Kisco,NY: Futura Publishing Co; 1975:260274.
Nodal blood supply
Studies on nodal blood supply principally by
James (1961) and Hutchinson( 1978)

- James : SA node - RCA 55% & LCA 45%
AV node- RCA 90% & LCA 10%

- Hutchinson : SA node - 65% & 35%
AV node- 80% & 20%

AV node may have dual supply in 2% cases
Arterial anastomoses
Seen at the intracoronary/inter-coronary levels in
abundance significant in development in
collaterals in CAD
Most abundant at the septum

Intracoronary : 1-2cm X 20- 250 micm
Inter-coronary: 2-3 cm X 20-350 micm
Coronary artery variations
2 coronary artery system is a recent evolutionary
acquisition

Fish and amphibia 1 coronary artery
Birds ~ 40% have single coronary arteries.

1-5% of those undergoing CAG


Angelini P Coronary artery anomalies current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines.
Tex Heart Inst J 2002;29:271-278
Coronary artery variations
Definition of a coronary artery is not based on its origin
and proximal course, but by focusing on its intermediate
and distal segments/ its dependent microvascular bed.


Angelini P Coronary artery anomalies current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines. Tex Heart Inst
J 2002;29:271-278
? Coronary artery Variation vs Anomalies
A broad spectrum of variations of which some
may cause adverse effects
Most of the coronary variations may have no
clinical implications as can be proven by
myocardial perfusion studies.

The regional distribution of a coronary artery,
rather than its absolute origin and
characteristics.

A puzzling issue..
Proximal course of the LAD may be very
different
LCx may run over atrial or ventricular surface.
An RCA that terminates in the AV groove well
before the crux may not always be an
obstruction: 7 10% (Grossman)
Double ostia from the RCS
All 3 arteries from a single sinus
One single artery..and so on
The most common coronary variation (Cleveland
Clinic-1,26,000 patients) was separate ostia for LAD &
LCX 0.41% and 2
nd
commonest was LCX from
RCS / RCA 0.37%




However, in another series of 1950 angiograms
coronary anomalies were seen in 5.6% cases and
split RCA (1.2%) was the commonest.
Angelina P. Coronary artery anomalies. Philadelphia, Lippincott Williams & Wilkins, 1999.
Level of variables
1) Ostium 2) Size 3) Proximal course
4) Mid-course 5) Intra-myocardial ramifications
6) Termination

MSCT with retrospective ECG gating is now
considered the gold standard for characterization of
coronary anomalies.
Prompt a search for underlying CHDs
1) Shi H, Aschoff AJ, Brambs HJ. Multislice CT imaging of anomalous coronary arteries. Eur Radiol. 2004;14:2172-2182.
2) Memisoglu E, Hobikoglu G, Tepe MS. Congenital coronary anomalies in adults: Comparison of anatomic course
visualized by catheter angiography and electron beam CT. Catheter Cardiovasc Interv. 2005;66:34-42.
Abnormal position of ostia
Coronary orifice below the cuspal margin:
- 10% RCS
- 15% LCS
Coronaries above the sinotubular jn ~ 6% - leads to difficult
cannulation, esp RCA with a high anterior ostium.
Abnormal number of coronary arteries
Single coronary artery - 0.024%, usually benign
D/d- 2 separate ostia from same sinus, atresia..
Course is important in 25% a major branch crosses
the infundibulum.
3 coronaries -
1) Separate origin of conus artery from RCS (36- 50%)
2) Absent LMCA with separate ostia for LAD & LCX
4 coronaries - case reports

Dual LAD- 0.13 -1% (Morettin ,1976)
Absent LMCA
~0.4%
- 1 ostia at the LCS/ 2 ostia in LCS/ 1 ostia in LCS & other RCS
- Increased incidence of Left dominance
- 6% incidence of bridging
- Not usually associated with CHDs
- Similar incidence of atherosclerosis
- Difficulty in selective cannulation

Topaz et al. Absent left main coronary artery: angiographic findings in 83 patients with separate ostia of the
left anterior descending and circumflex arteries at the left aortic sinus.
Am Heart J.1991 Aug;122(2):447-52.

Shepherds-crook RCA
~5%
Acute superiorly angled take-off of the RCA
from the aorta.
Difficult RCA lesion angioplasty
Ethan Halpern. Cardiac CT . Functional anatomy.
Dual LAD (Duplication)
~0.13 - 1% of normal hearts
Proximal LAD (LAD proper) bifurcates early into a
short and long LAD
-Type I : Short LAD in AIVS, Long LAD on prox AIVS, LV side, distal AIVS

-Type II : Short LAD in AIVS, Long LAD on prox AIVS, RV side, distal AIVS

-Type III: Short LAD in AIVS, Long LAD intra-myocardially in septum

-Type IV: Very short LAD proper and short LAD, Long LAD from RCA
Spindola-Franco H et al. Dual left anterior descending coronary artery: angiographic description of Important variants
and surgical implications. Am Heart J 1983:105;44555.
Coronary artery Ectasia
1 - 5% in angiographic series, more in males
20- 30 % are congenital
Dialatation of a segment to at least 1.5times of the
adjacent normal coronary artery.

Coronary venous anatomy
Targeted drug delivery

Retrograde cardioplegia administration

Potential conduit to bypass cor. artery stenosis

Stem cell delivery to the infarcted region

Access to LA & LV myocardium for arrythmia mapping
& ablation

LV epicardial pacing in CRT
Coronary venous anatomy
THEBESIAN veins Venae cordis minimae
Conventional coronary venous
nomenclature
Coronary sinus - Thebasian valve
Anterior IV vein(Great cardiac vein) - Vieussens valves
- Left marginal vein of LV
- Postero-lateral LV vein
Middle cardiac vein
Small cardiac veins


SEGMENTAL CLASSIFICATION

Segmental venous classification
Thus 9 LV venous segments are derived which when added with the
conventional classification gives the best comprehensive information to place
the epicardial LV leads for CRT purposes
Retrograde coronary venography

MDCT angiogram delineating coronary
veins along with arteries
Coronary Angiographic Views
Cardiac Cath 1
st
by Werner Forssman in 1929
1
st
contrast angiography by Chavez in 1947
CART 1
st
performed by F. Mason Sones in 1958

a high-resolution image-intensifier television system with digital
cineangiographic capabilities.

- Radiograph tube below and Image intensifier above
(Flouroscopic imaging system with C-arm)

- Physiologic monitoring system, sterile supplies, resuscitation
equipment, Contrast injector (3-8ml/sec) and contrast media
Information from a CAG:

CAG helps visualization of the major epicardial arteries up
to their 2
nd
and 3
rd
order branches


- Coronary anatomy
- Characteristics and distribution of coronary stenosis
- Distal vessel size
- Intracoronary thrombus
- Index of coronary flow
- Mass of myocardium served
- Collateral vasculature



Optimal injection rate: 7ml (2.1ml/s) for LCA and 4.8ml (1.7ml/s) for RCA


Pitfalls of CAG
A Lumenogram
Interpretation of the significance of a
lumenogram
Multiple projections from different angles, preferably
orthogonal

Knowledge of the normal calibre of major coronaries:
LMCA: 4.5 0.5 mm
LAD: 3.7 0.4 mm
LCX : 3.5 0.5 mm ( 4.2 mm if dominant)
RCA: 3.9 0.6 mm ( 2.8 mm if non-dominant)

IVUS
Functional studies : FFR
Mistakes in CAG interpretation
Inadequate number of projections used
Improper/inadequate contrast injection
Super-selective injection
Catheter induced vasospasm
Coronary artery variations
Myocardial bridges
Total ostial occlusions
Wire induced spasm (ACCORDION EFFECT)

LAO and RAO views help furnish the true PA and
lateral views of the heart
D/A s - foreshortening
- superimposition

Cranial view: Image-intensifier tilted towards head
Caudal view: Image-intensifier tilted towards the feet

-however the optimal angiographic view varies with
coronary anatomy, body habitus and location of lesion
Angiographic projections
Angiographic projections
Kern MJ. Cardiac Catheterization Handbook. 5
th
edition,2011.
RAO and LAO projections
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
RAO- LCA
RAO- RCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
Shallow RAO cranial - LCA
AP cranial - LCA
RAO cranial - RCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
RAO caudal - LCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
AP (Shallow RAO) caudal- LCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
LAO - LCA
LAO - RCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
LAO cranial - LCA
LAO cranial - RCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
LAO caudal (Spider view) - LCA
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
Lateral view
Mid & distal LAD

Proximal LCX

Mid RCA

LIMA graft to LAD
Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING
Heart 2005;91:968976.
There is no single magical projection that can be
applied uniformly to all patients for visualizing
a particular coronary atery
Panoramic coronary angiography
GIORGIO TOMMASINI et al. Panoramic Coronary Angiography. JACC 31(4),March 15, 1998:8717
References
Hursts The Heart 13
th
Edition
Braunwalds Heart Disease 9
th
edition
Greys Anatomy
Kerns Handbook of Interventional Catheterization
Kjell C Nikus. Coronary angiography.
Grossmans Textbook of Cardiac Catheterization
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY
ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968976
David M Fiss. Normal coronary anatomy and anatomic variations. Applied
Radiology, Jan 2007.
Horia Muresian. Coronary arterial anomalies and variations. MAEDICA. A journal
of clinical Medicine,1(1), 2006.
Singh et al. The coronary venous anatomy. A segmental approach to aid CRT
2005, 46(1), 68-74.
Shilpa Bhimali et al. A STUDY OF VARIATIONS IN CORONARY ARTERIAL SYSTEM IN
CADAVERIC HUMAN HEART. World Journal of Science and Technology 2011, 1(5):
30-35 ISSN: 2231 2587.