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4 - Cine Angiography

Cine angiography obtains multiple images of the coronary arteries to precisely diagnose coronary artery disease. It identifies significant blockages, their location and characteristics. This information is used to develop treatment strategies. The procedure evaluates vessel size, disease progression, and possible bypass grafting sites. Standard views are taken to assess the left main, left anterior descending, circumflex, and right coronary arteries and their branches. Lesion classification guides treatment likelihood and risks. Patient and technical factors can impact image quality.

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Yonatan Merchant Perez

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0% found this document useful (0 votes)

39 views54 pages

4 - Cine Angiography

Uploaded by

Yonatan Merchant Perez

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PPT, PDF, TXT or read online on Scribd

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Cine Angiography

05/25/23 22:39
Cine Angiography

The goal of Cine Angiography is to obtain

multiple quality images of the coronary
arteries and their branches to make a
precise diagnosis. Based on the
angiographic information, an
interventional strategy will be developed
for the treatment of the patients coronary
artery disease
Cine Angiography

With Cine Angiography the following

information about the patients CAD must be
determined:

• Identification of significant disease

• Location of the disease
• Lesion Characteristics
• Involvement of side branches
• LV Function
Cine Angiography

Other subsequent information that the physician

can gather from the angiograms:

• Vessel Size / Diameter

• Possible anastomotic sites for CABG’s
• Disease progression
Cine Angiography

Review of coronary distribution

The Left Main:

The typical length of the Left Main:

• varies from 0 to 20mm’s with diameters

The typical diameter of the Left Main:

• varies between 3 to 6mm’s
The Left Main - LM

•Disease in this portion

of a patients artery is
known as the “Widow
Maker” due to its high
associated mortality

•Branches off the LM

are the LAD and CFX
Cine Angiography

Review of coronary distribution

The Left Anterior Descending Artery supplies blood

to the following:

• Anterior 2/3 of the Lt Ventricle

• Anterior portion of the Rt Ventricle
• Lower aspect of the posterior Rt Ventricle
• Apex and Mid-septum, which includes the
Bundle of HIS
The Left Anterior Descending Artery -
LAD

•Major branches are

know as Diagonals

•Smaller branches are

known as Septals
Cine Angiography

Review of coronary distribution

The Rhamus or Intermediate Artery

• Arises between the LAD and Circumflex

arteries
• Creates a “Trifurcation” from the divisions of
the LAD, CFX and Intermediate
• Runs parallel to the Diagonal branches of the
LAD and the Marginal branches of the
Circumflex
The Rhamus /Intermediate Artery

•The Rhamus or
Intermediate artery
provides blood to the
anterior and posterior
lateral portions of the
heart

•Not common in all

patients
Cine Angiography

Review of coronary distribution

The Circumflex or “Circ” supplies blood to the

following:

• Lateral wall and 1/2 of the posterior wall of the Left

Ventricle
• The Left Atrium
• Sino-Atrial Node (in some people)
• May also supply the Left Ventricle and Septum
The Circumflex or “Circ”

•Major branches are

known as Obtuse
Marginals and are
numbered in the order
which they arise,
proximal to distal.
(i.e. 1st OM, 2nd OM
and so on)

•In 15% of patients

the PDA may arise of
the Circ
The Right Coronary Artery - RCA

Review of coronary distribution

The Right Coronary Artery - RCA supplies blood

to the following:

• Inferior wall of the Left Ventricle

• Anterior wall of the Right Ventricle
• Right Atrium
• Posterior position of the Septum
• SA and AV Nodes
The Right Coronary Artery - RCA

Major branches are

known as:

•The Conus
•The SA Nodal
•The AV Nodal
•The Acute Marginal
•The Posterior Lateral
•The Posterior Descending
The Concept of Dominance

The dominant vessel is indicated by which artery is

responsible for supplying blood to:

• The posterior diaphragmatic (inferior) portion of

the Intraventricular Septum

• The diaphragmatic (inferior) surface of the Left

Ventricle
The Concept of Dominance

Left Dominance

• Occurs in approximately 15% of the overall patient

population
– 8% strictly Circumflex dominant
– 7% co-dominant
• Artery descends to the crux of the heart from
significant Marginal arteries
• RCA is typically much smaller
The Concept of Dominance

Right Dominance

• Occurs in approximately 85% of the overall patient

population
• Right dominant system does not indicate that the
RCA is more important than the LCA and vice versa
Cine Angiography

Assessing the significance of disease

• Done with “QCA” (Quantitative Coronary

Angiography). Essentially the physicians best
estimate by comparing “healthy” or “normal”
appearing vessel to that of the diseased
segment.

• Multiple views / angles taken

Cine Angiography

Determinates in the significance of the disease

and lesion classifications

• Normal - Healthy, non-diseased vessel

• Irregularities - “Rippling” on vessel
• Non significant stenosis - Stenosis < 50%
• Significant stenosis - Stenosis 50 - 75%
• Subtotal Occlusion - Stenosis 75 - 90%
• Total Occlusion - Stenosis > 95%
Cine Angiography

•Normal

•Irregularities

•Non - significant

•Significant

•Subtotal Occlusion

•Total Occlusion
Flow / Flow Restrictions
TIMI Flow
Standard which was used during the TIMI Trials
to assist in the grading of angiographic flow 90
minutes following the use of Thrombolytic Therapy

• TIMI 0 - No perfusion
• TIMI 1 - Penetration with minimal perfusion,
contrast fails to opacify the entire bed
distal to the stenosis.
• TIMI 2 - Partial perfusion, contrast opacifies the
entire bed distal to the stenosis. However,
the rate is slower.
• TIMI 3 - Complete & normal perfusion
AHA Lesion Classifications

• Designed by the ACC and AHA to develop a

lesion specific classification guide for estimating
the likelihood of a successful procedure as well
as the potential of abrupt vessel closure.

• The angiographic appearance of the vessels are

used to place them in one of the following
categories.
Type A Lesions

• Discrete < 10mm in length

• Concentric
• Readily accessible
• Non-angulated segment < 45
• Smooth contours
• Little or no calcification
• Not ostial in location
• No major side branch involvement
• Absence of thrombus
Type A Lesions

LAD

•Discrete focal lesion

•Concentric

•Readily accessible

•Smooth contours
Type B Lesions

• Tubular 10 - 20mm’s in length

• Eccentric
• Moderate tortuosity of proximal segment
• Moderate angulated segment > 45 - 90
• Irregular contours
• Moderate to heavy calcification
• Total occlusion < 3 months
• Ostial location
• Bifurcation lesions
• Some thrombus present
Type B Lesions (B1 and B2)

RCA

•Eccentric lesion
•Moderately angulated
segment
•Thrombus present
Type C Lesions

• Diffuse > 2cm length

• Excessive tortuosity of proximal segment
• Extremely angulated segments > 90
• Total occlusion > 3 months old
• Inability to protect major side branches
• Degenerated vein grafts with friable lesions
Type C Lesions

RCA

•Excessive tortuosity of
proximal segment

•Near or Total Occlusion

> 3 months
Cine Angiography

Patient factors effecting Cine Angiography

• Patient size

• Movement during imaging

• Pacemaker, Surgical implants, etc.

• Patients condition

• Patients ability to follow commands

Cine Angiography

Procedural factors effecting Cine Angiography

• Catheter shape, size, curve

• Poor vessel opacification
• Cine film - fogged or exposed
• Film processing
• Imaging equipment
– inadequate or over penetration
Cine Angiography

Routine Cine Views and their effect on the anatomy

• AP - Anterior to Posterior

• Lateral - at the side (Right or Left)

• Oblique - RAO or LAO

• Cranial - towards the head

• Caudal - towards the feet

Cine Angiography

AP - Anterior Posterior

• The X-ray camera is

positioned directly over
the patient with the X-ray
beam perpendicular to the
patient lying on the table
Cine Angiography

Lateral

• The X-ray camera is

positioned to either side
of the patient lying on
the table
Cine Angiography

RAO - Right Anterior

Oblique

• The X-ray camera is

angled to the Right of the
patient lying on the table.
Cine Angiography

LAO - Left Anterior Oblique

• The X-ray camera is

angled to the Left of the
patient lying on the table.
Cine Angiography

Cranial

• In the cranial views, the

X-ray camera is tilted
towards the patients
head.
Cine Angiography

Caudal

• In the caudal views,

the X-ray camera is
tilted towards the
patients feet.
Cine Angiography

Standard Imaging Sequences

LCA RCA
•RAO 10 - 15 •LAO 30
•RAO 30 •RAO 30
•RAO 60 w/ 15 Caud
•RAO 60 w/ 30 Cran LV
•LAO 60 w/ 15 Cran
•RAO 30
•Lateral
•LAO 60 w/ 30 Caud
Cine Angiography

Tips for Cine film interpretation

Spine Location

• The spine is always located on the opposite side

that the cine view is being taken, i.e.

– In a RAO, the spine is always on the Left

– In a LAO, the spine is always on the Right
Cine Angiography

Tips for Cine film interpretation

Rib Location

• The ribs are always on the same side that the

cine view is being taken, i.e.

– In a RAO, the ribs are always on the Right

– In a LAO the ribs are always on the Left
Cine Angiography

Tips for Cine film interpretation

Location of the Diaphragm

• When you can see the diaphragm in the view,

you are usually in a Cranial view.
• However, the exception to the rule is
dependant the patients ability to take in a
large enough breath.
Cine Angiography

Differentiating between the LAD and Circ

• Determine which vessel stretches to the apex of

the heart, this will be the LAD.
• Look for the Septal branches
• The Circumflex is always* the closest to the spine