Coronary Angiography

1. Coronary Angiography Sripal Bangalore, M.D., M.H.A. and Deepak L. Bhatt, M.D., M.P.H., F.A.H.A

2. Overview Coronary Angiography • Indications • Contraindications / Caution • Equipment • Equipment & Technique • Precautions • Pressure monitoring • Zeroing and Referencing • Guide catheter selection • Flow rate and volume • Standard angiographic views • Angiogram- interpretation • ACC/AHA lesion classification • Other definitions • TIMI flow and perfusion grades • Congenital coronary anomalies

3. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • CCS class III and IV angina on medical treatment • High-risk criteria on noninvasive testing regardless of anginal severity • Patients who have been successfully resuscitated from sudden cardiac death or have sustained (>30 seconds) monomorphic ventricular tachycardia or non-sustained (<30 seconds) polymorphic ventricular tachycardia • Angina in patients who are not candidates for coronary revascularization or in whom revascularization is not likely to improve quality or duration of life • As a screening test for CAD in asymptomatic patients • After CABG or angioplasty when there is no evidence of ischemia on noninvasive testing • Coronary calcification on fluoroscopy, electron beam computed tomography, or other screening tests without criteria listed above B A Known or suspected CAD (Class I and III only) B C C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

4. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I Patients With Nonspecific Chest Pain • High-risk findings on noninvasive testing • Patients with recurrent hospitalizations for chest pain who have abnormal (but not high-risk) or equivocal findings on noninvasive testing • All other patients with nonspecific chest pain B B C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

5. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures) • An early invasive strategy is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events • An early invasive strategy is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization • An early invasive strategy is not recommended in patients with acute chest pain and a low likelihood of ACS • An early invasive strategy should not be performed in patients who will not consent to revascularization regardless of the findings B Patients With Unstable Acute Coronary Syndromes (Class I and III only) A C C C Source: Anderson JL et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1–157

6. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • Diagnostic coronary angiography should be performed: • In candidates for primary or rescue PCI • In patients with cardiogenic shock who are candidates for revascularization • In candidates for surgical repair of ventricular septal rupture (VSR) or severe MR • In patients with persistent hemodynamic and/or electrical instability • Coronary angiography should not be performed in patients with extensive comorbidities in whom the risks of revascularization are likely to outweigh the benefits Patients With STEMI (Class I and III only) A A B C C Source: Antman EM et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2004. Available at www.acc.org/clinical/guidelines/stemi/index.pdf.

7. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • Suspected abrupt closure or subacute stent thrombosis after percutaneous revascularization. • Recurrent angina or high-risk criteria on noninvasive evaluation within 9 months of percutaneous revascularization • Symptoms in a post bypass patient who is not a candidate for repeat revascularization • Routine angiography in asymptomatic patients after percutaneous transluminal coronary angioplasty (PTCA) or other surgery, unless as part of an approved research protocol B Patients With Post-revascularization Ischemia (Class I and III only) C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

8. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • Evidence for high risk of adverse outcome based on noninvasive test results • Angina unresponsive to adequate medical therapy • Unstable angina, particularly when facing intermediate or high-risk noncardiac surgery • Equivocal noninvasive test result in a high-clinical- risk in patients • Low-risk noncardiac surgery, with known CAD and no high-risk results on noninvasive testing • Asymptomatic after coronary revascularization with excellent exercise capacity (>7 METs) • Mild stable angina with good left ventricular function and no high-risk noninvasive test results • Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (eg, LVEF <0.20), or refusal to consider revascularization. • Candidate for liver, lung, or renal transplant >40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome C C C Perioperative Evaluation Before (or After) Noncardiac Surgery (Class I and III only) C B C B C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

9. Indications IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • Before valve surgery or balloon valvotomy in an adult with chest discomfort, ischemia by noninvasive imaging, or both • Before valve surgery in an adult free of chest pain but of substantial age and/or with multiple risk factors for coronary disease • Infective endocarditis with evidence of coronary embolization • Before cardiac surgery for infective endocarditis when there are no risk factors for coronary disease and no evidence of coronary embolization • In asymptomatic patients when cardiac surgery is not being considered • Before cardiac surgery when preoperative hemodynamic assessment by catheterization is unnecessary, and there is neither preexisting evidence of coronary disease nor risk factors for CAD B Patients With Valvular Heart Disease (Class I and III only) C C C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

10. Indications I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • Before surgical correction of congenital heart disease when chest discomfort or noninvasive evidence is suggestive of associated CAD • Before surgical correction of suspected congenital coronary anomalies such as congenital coronary artery stenosis, coronary arteriovenous fistula, and anomalous origin of left coronary artery • Forms of congenital heart disease frequently associated with coronary artery anomalies that may complicate surgical management • Unexplained cardiac arrest in a young patient • In the routine evaluation of congenital heart disease in asymptomatic patients for whom heart surgery is not planned C Patients With Congenital Heart Disease (Class I and III only) C C B C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

11. Indications I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I • CHF due to systolic dysfunction with angina or with regional wall motion abnormalities and/or scintigraphic evidence of reversible myocardial ischemia when revascularization is being considered • Before cardiac transplantation • CHF secondary to postinfarction ventricular aneurysm or other mechanical complications of MI. • CHF with previous coronary angiograms showing normal coronary arteries, with no new evidence to suggest ischemic heart disease B Patients With CHF (Class I and III only) C C C Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357

12. Contraindications • There are no absolute contraindications to cardiac catheterization • Relative contraindications include: • Coagulopathy (Radial approach can be attempted based on urgency) • Decompensated congestive heart failure • Uncontrolled hypertension • Pregnancy • Inability for patient cooperation • Active infection • Renal failure • Contrast medium allergy

13. Equipment & Technique • Conscious sedation using a narcotic and a benzodiazepine • Vascular access: Either femoral (described in the section on vascular access and closure devices), radial, or brachial • Flush the selected diagnostic catheter with saline to ensure an air-free system • Once arterial access is obtained (as described in the section on vascular access and closure devices) a catheter of appropriate size and configuration is advanced over a 0.035 or 0.038 inch guidewire • Once in the ascending aorta, the guidewire is removed, the catheter allowed to bleed back to remove any thrombus or atherosclerotic debris • The catheter is then connected to a manifold assembly connected to a pressure transducer for continuous central pressure monitoring • The catheter is flushed to ensure an air-free system

14. Technique • Zeroing and referencing: The transducer should be opened to air to zero the system. Care must be taken to ensure that the pressure transducer is at the level of phlebostatic axis, which is roughly the midportion between the anterior and posterior chest wall along the left 4th intercostal space • The central aortic pressure should be recorded and compared with the cuff measured brachial pressure. If there is considerable difference between the two, subclavian artery stenosis should be in the differential • The catheter should then be filled with 3-4 cc of contrast and advanced to engage the coronary ostium, in the LAO projection • After ensuring that there is no ventricularization or damping of the pressure, a 2 to 3 cc of contrast should be injected to confirm the position of the catheter in the coronary ostium

15. Technique • Coronary angiography should be performed in standard views in orthogonal planes to visualize the lesion and serve as a roadmap for PCI • Non-standard views should be considered based on the lesion location, orientation of the heart, and patient body habitus • Before injecting contrast, with every view care should be taken to ensure no ventricularization or damping of the pressure wave forms

16. Complications • The overall risk of major complications with coronary angiography is 1-2%. This includes death, myocardial infarction, stroke, bleeding, vascular complications and contrast reaction.

17. Catheter Selection • Selecting the right catheter is important and is dependent upon the following: • Access site: Choice of catheters depends to certain degree on the access site - femoral vs. radial vs. brachial • Aortic width: Normal aortic width - 3.5 to 4.0 mm; Narrow- <3.5 mm, Dilated >4.0 mm • Coronary ostial location: high vs. low; anterior vs. posterior • Coronary ostial orientation: Superior, inferior, horizontal or shepherd’s crook (for RCA only) • Standard workhorse catheters for routine coronary angiography are Judkins right size 4 (JR4) and Judkins left size 4(JL4) and the ostia are engaged in the LAO projection • Always ensure co-axial alignment of the catheter • Catheters generally have two curves: Primary (distal) curve and a secondary (proximal) curve. The distance between the two curves is the length of the catheter • Shorter curve more ideal for superior take-offs • Longer curve more ideal for inferior take-offs

18. Flow Rate and Volume • If using a power injector for contrast opacification, the following settings may be considered: • RCA- 2 to 3ml/sec for 2 to 3 seconds, i.e., 3 for 6 represents a flow rate of 3ml/sec for a total volume of 6ml • LCA- 3 to 4ml/sec for 2 to 3 seconds, i.e., 4 for 8 which represents a flow rate of 4ml/sec for a total of 8ml • Ventriculography - 10 to 16ml/sec for 30 to 55ml, i.e., 13 for 39 which represents a flow rate of 13ml/sec for a total of 39ml • Common carotid artery - 8ml/sec for 10 cc • Internal carotid artery - 8ml/sec for 8cc • Vertebral artery - 7ml/sec for 7cc • Renal artery - 5ml/sec for 5 to 10cc • Iliofemoral - 7 to 9ml/sec for 70 to 120 cc Source: Baim, DS et al. Grossman’s Cardiac catheterization, angiography and intervention. Lippincott Williams & Wilkins, Philadephia

19. Standard Angiographic Views Left Coronary Artery • LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal • Best for visualizing left main, proximal LAD and proximal LCx • RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal • Best for visualizing left main bifurcation, proximal LAD and the proximal to mid LCx • Shallow RAO-Cranial view: 00 to 100 RAO and 250 to 400 cranial • Best for visualizing mid and distal LAD and the distal LCx (LPDA and LPL) • Separates out the septals from the diagonals • LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial • Best for visualizing mid and distal LAD, and the distal LCx in a left dominant system • Separates out the septals from the diagonals

20. Standard Angiographic Views Left Coronary Artery (other views) • PA projection: 00 lateral and 00 cranio-caudal • Best for visualizing ostium of the left main • PA-Caudal view: 00 lateral and 200 to 300 caudal • Best for visualizing distal left main bifurcation as well as the proximal LAD and the proximal to mid LCx • PA-Cranial view: 00 lateral and 300 cranial • Best for visualizing proximal and mid LAD • Left lateral view: • Best for visualizing proximal LCx, proximal and distal LAD • Also good for visualizing LIMA to LAD anastomotic site

21. Standard Angiographic Views Right Coronary Artery • LAO 30: 300 LAO • Best for visualizing ostial and proximal RCA • RAO 30: 300 RAO • Best for visualizing mid RCA and PDA • PA Cranial: PA and 300 cranial • Best for visualizing distal RCA bifurcation and the PDA

22. Standard Angiographic Views • An easy way to identify the tomographic views is to use the anatomic landmarks - catheter in the descending aorta, spine and the diaphragm. The rough rules are: • RAO vs. LAO- If the spine and the catheter are to the right of the image, it is LAO and vice versa. If central, it is likely a PA view • Cranial vs. caudal - If diaphragm shadow can be seen on the image, it is likely cranial view, if not, it is caudal Spine to the RIGHT LAO view Cranial view Catheter at the CENTER Catheter and spine to the LEFT PA view Diaphragm shadow RAO view Caudal view Caudal view No diaphragm shadow No diaphragm shadow

23. Standard Angiographic Views Left Coronary Artery LAD LAD LM Diagonal LCx Septals Distal LAD Distal LAD fills by collaterals RAO 20 Caudal 20 RAO 20 Caudal 20 Best for visualization of LM bifurcation and proximal LAD and LCx Knowledge of the orientation of the artery for a given view can help identify the probable path of the artery in the setting of complete occlusion

24. Standard Angiographic Views Left Coronary Artery LM LCx LCx LM LAD LAD Diagonal Septals Diagonal Septals Distal LAD Distal LAD LAO 50 Cranial 30 PA 0 Cranial 30 Best for visualization of proximal and mid LAD and splaying of the septals from the diagonals. Also ideal for visualization of distal LCx Best for visualization of LM proximal and mid LAD

25. Standard Angiographic Views Left Coronary Artery Diagonal LAD LAD Diagonal LM LM OM LCx LCx Septals Distal LAD Distal LAD OM LAO 50 Caudal 30 PA0 Caudal 30 ‘Spider’ view Best for visualization of LM bifurcation and proximal LAD and LCx Best for visualization of LM bifurcation, proximal LAD and LCx and OM

26. Standard Angiographic Views Right Coronary Artery Proximal RCA Proximal RCA Mid RCA Distal RCA PDA Mid RCA Mid RCA PDA PDA/PLV Distal RCA LAO 30 RAO 30 PA 0 Cranial 30 Best for visualization of ostial and proximal RCA Best for visualization of mid RCA and PDA Best for visualization of distal RCA and its bifurcation

27. Angiogram-Interpretation • A systematic interpretation of a coronary angiogram would involve: • Evaluation of the extent and severity of coronary calcification just prior to or soon after contrast opacification • Lesion quantification in at least 2 orthogonal views: • Severity • Calcification • Presence of ulceration/thrombus • Degree of tortuosity • ACC/AHA lesion classification • Reference vessel size • Grading TIMI flow • Grading TIMI myocardial perfusion blush grade • Identifying and quantifying coronary collaterals

28. ACC/AHA Lesion Classification • Type A Lesion:Minimally complex, discrete (length <10 mm), concentric, readily accessible, non-angulated segment (<45°), smooth contour, little or no calcification, less than totally occlusive, not ostial in location, no major side branch involvement, and absence of thrombus • Type B Lesion:Moderately complex, tubular (length 10 to 20 mm), eccentric, moderate tortuosity of proximal segment, moderately angulated segment (>45°, <90°), irregular contour, moderate or heavy calcification, total occlusions <3 months old, ostial in location, bifurcation lesions requiring double guidewires, and some thrombus present • Type C Lesion: Severely complex, diffuse (length >2 cm), excessive tortuosity of proximal segment, extremely angulated segments >90°, total occlusions >3 months old and/or bridging collaterals, inability to protect major side branches, and degenerated vein grafts with friable lesions. Source: Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiology. 1988;12:528-45

29. Other Definitions • Lesion length: Measured “shoulder-to-shoulder” in an unforeshortened view • Discrete Lesion length < 10 mm • Tubular Lesion length 10–20 mm • Diffuse Lesion length ≥ 20 mm • Lesion angulation: Vessel angle formed by the centerline through the lumen proximal to the stenosis and extending beyond it and a second centerline in the straight portion of the artery distal to the stenosis • Moderate: Lesion angulation ≥ 45 degrees • Severe: Lesion angulation ≥ 90 degrees • Calcification: Readily apparent densities noted within the apparent vascular wall at the site of the stenosis • Moderate: Densities noted only with cardiac motion prior to contrast injection • Severe: Radiopacities noted without cardiac motion prior to contrast injection

30. TIMI Flow Grades • TIMI 0 flow:absence of any antegrade flow beyond a coronary occlusion • TIMI 1 flow:(penetration without perfusion) faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed • TIMI 2 flow: (partial reperfusion) delayed or sluggish antegrade flow with complete filling of the distal territory • TIMI 3 flow: (complete perfusion) is normal flow which fills the distal coronary bed completely Gibson CM, et al. Am Heart J. 1999;137:1179–1184

31. TIMI Myocardial Perfusion Grades • Grade 0:Either minimal or no ground glass appearance (“blush”) of the myocardium in the distribution of the culprit artery • Grade 1:Dye slowly enters but fails to exit the microvasculature. Ground glass appearance (“blush”) of the myocardium in the distribution of the culprit lesion that fails to clear from the microvasculature, and dye staining is present on the next injection (approximately 30 seconds between injections) • Grade 2: Delayed entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) of the myocardium that is strongly persistent at the end of the washout phase (i.e. dye is strongly persistent after 3 cardiac cycles of the washout phase and either does not or only minimally diminishes in intensity during washout). • Grade 3: Normal entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) of the myocardium that clears normally, and is either gone or only mildly/moderately persistent at the end of the washout phase (i.e. dye is gone or is mildly/moderately persistent after 3 cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout phase), similar to that in an uninvolved artery. Gibson CM, et al. Circulation. 2000;101:125-130

32. Coronary Aneursym • Coronary Aneurysm: Vessel diameter > 1.5x neighboring segment • Incidence: 0.15%-4.9%; very rare in LMCA • Etiology: mainly atherosclerosis; other causes include Kawasaki’s, PCI, inflammatory disease, trauma, connective tissue disease • Treatments: include observation, surgery, occlusive coiling, covered stents, therapeutic coiling Image courtesy Dr. Frederick Feit

33. Coronary Anomalies LM LAD RCA Anomalous LCx from right cusp Anomalous RCA from left cusp Image courtesy Dr. Frederick Feit Image courtesy Dr. Frederick Feit Prognosis benign Prognosis benign • Left coronary artery arising from the right sinus of Valsalva - course relative to great vessels must be defined as interarterial course portends an increased risk of sudden death

34. Coronary Anomalies LCX LCX LAD AORTA AORTA LAD PULMONARY ARTERY PULMONARY ARTERY LM LM RCA RCA Anomalous LCA from right sinus - Inter-arterial Course Anomalous LCA from right sinus - Retro-aortic course Increased risk of sudden death Prognosis benign