Understanding Coronary Angiogram Views, Structures, and Troubleshooting: A Comprehensive Guide

Coronary Angiography

Cardiac Cath Practice Cases with Answers:


Basic Views of Coronary Angiogram:

Coronary angiography is a crucial diagnostic tool used to assess the coronary arteries' health and detect blockages or abnormalities. This procedure involves injecting a contrast dye into the coronary arteries and capturing X-ray images to visualize blood flow and identify potential issues. Understanding the various angiogram views, structures visible, and troubleshooting techniques is essential for healthcare professionals involved in cardiac care.

1. Basic Coronary Angiogram Views:
   - Right Anterior Oblique (RAO) View: Provides a clear visualization of the right coronary artery (RCA) and its branches.
   - Left Anterior Oblique (LAO) View: Offers a detailed look at the left coronary artery (LCA) system, including the left main coronary artery (LMCA), left anterior descending artery (LAD), and left circumflex artery (LCx).
   - Cranial/Caudal Views: These views help assess the vertical orientation of coronary arteries, aiding in the identification of lesions and stenosis.

2. Structures Visible:
   - Left Main Coronary Artery (LMCA): Arises from the aortic root and bifurcates into the LAD and LCx arteries, supplying blood to the left side of the heart.
   - Left Anterior Descending Artery (LAD): Descends along the anterior interventricular groove, supplying blood to the anterior wall of the left ventricle.
   - Left Circumflex Artery (LCx): Wraps around the left side of the heart, supplying blood to the lateral and posterior walls of the left ventricle.
   - Right Coronary Artery (RCA): Travels along the right atrioventricular groove, supplying blood to the right atrium, right ventricle, and parts of the septum.
   - Coronary Artery Branches: Include diagonal branches (from LAD), obtuse marginal branches (from LCx), and posterior descending artery (from RCA), among others.

3. Troubleshooting Techniques:
   - Inadequate Contrast Opacification: Adjust the injection rate or volume of contrast to ensure optimal visualization of coronary arteries.
   - Catheter Positioning Issues: Check for catheter tip placement within the ostium of the target coronary artery and make necessary adjustments.
   - Coronary Artery Spasm: Administer vasodilators such as nitroglycerin to relieve spasm and improve coronary artery visualization.
   - Patient Motion Artifact: Minimize patient movement and ensure proper sedation or anesthesia to reduce motion artifacts during the procedure.
   - Contrast Allergy or Renal Dysfunction: Pre-screen patients for allergies or renal impairment and use alternative contrast agents if necessary.

Coronary angiography is a valuable tool for diagnosing coronary artery disease and guiding treatment decisions. Understanding the various angiogram views, structures visible, and troubleshooting techniques is essential for healthcare providers to obtain accurate results and ensure patient safety during the procedure. Continued education and training in coronary angiography are vital for healthcare professionals to maintain competency and deliver high-quality cardiac care.

Coronary Angiogram Case Discussions:

This patient is a female patient, 73 years old, female and odmission with effort chest pain. And this patient has a particular past Fisher history. Two years ago this patient has Led osteo region. So underwent sten crossover from the Led osteome to the distal Lemaine. One years later and experience ISR the Led osteom so received drug loading balloon for that lesion. And the six months later this patient has also recurrent is osteom region. So repeat the balloon angioplasty. And this time we have another suck osteo list hemorrhagic region. And the risk factor is the hypolidemia. No diabetic, no hypertension. The ejection fraction was normal. Okay, so as you heard actually, would you show the angiogram? Okay, that's good. So this is the angiogram just showed minimal intimacy of a stentid segment from the Led to le main as may intermediate stenosis and critical arrowings over circumflex of cell part very discrete. However, this is clear the significant stenosis. Would you show another view? Okay. Daron. All right. This is spider view as clear some hedgenes and very tighter stenosis and Circumflex ostel part and some intermediate stenosis and Led stented segment. And so we are going to treat osteom non stented segment and we have to consider gain about the main stented segment from Led to the main. This is the stent crossover, the Circumference osteomy stenosis already plus the fact this is a distal bifurcation left main disease. Has there been any thought about surgery after they made this MDT discussion with the surgeons? Have you discussed with the surgeons possibility of a bypass operation? Yeah. All right. We clearly consider the possibility of pipeline surgeries. However, a Circumflex Australia part resources to be the first time. And this is very Angelo Angelographically discrete religion and the intervention inside. I can do the intervention, repeat intervention for Circumflex osteopathy. Very clear. So they are a major vessel. So already is hemodynamically, maybe scurred. It's not functionally. Cynical stenosis maybe mainly related with Circumflex osteo disease. And so still, I believe PCI would be another option for a particular dispatient reasonable options on a surgery at any time for the main disease. Surgery is good. Any other suggestion for that? Would your strategy be the same had the patient been diabetic? Did you hear us? No diabetes, but had he been diabetic. Good strategy. I mean, what is your strategy overall? I mean PCI yes, but what is your plan for the Remain disease? Yes, all right. You may know that last two years lots of changes in terms of, you know, ESSC guideline and even in the HH guideline for the remainders. Personally, I believe still I don't believe it's much about morphologic certification, just like syntax quizzo. However, if we look at the guideline concern low end, intermediate osile. Any limb main disease still good candidate. Candidate for angel. Plus the meaning is for lem. Main disease whole populations at least more than two. Salt. Exactly say it's more than 67%. Almost 70% of cases would be good for the intervention personality, I believe showed the previous one. So I believe this kind of simple not actually not simple, this is regional cases, however, morphologically quite simple and the other vessels is good. Still, I believe it is a good candidate for PCI. So that's good. So what is your strategy? How do you plan to do this case now? Right, actually we are going to do IBC evaluation in post branches. However, before that, according to the based on the angiographic findings, there's many osteo sarcomfact disease and so we have some options balloon angioplasty and just triggering balloon for the discrete narrowing of a circumflex osteum and another stand for the circumfix osteum. Whatever you choose, tap technique or cooler technique. I think it doesn't mean anything, right? We can do another stand for the circumflex osteom and then for the Led side we want to see that what happens by obviously evaluation and maybe related with some underexpension or intimate hyperpleasure depending on that. We want to do the more standard if the lesion related with under expansion, et cetera. However, enough stent expansion and intimate hyperplays. We want to do simple plain balloon angel plaster first, or sometimes we practically prefer coating balloon for the stented sigma. And then from the beginning we discussed about that just circumflex whole part. We want to choose another stent and then decide. We want to do the depending on a morphology by iris and coding balloon and drug living balloon for stent in the segment and use stent. In terms of a technical concern, I prefer particular for these cases as a tab technique, minimal proximal protrudings in the main branches side. It is more easier to do some procedures even in the complex Remain disease. So that is our plan. Have you thought about using for that? Have you thought about using a dedicated stent in particular in this case, maybe a triton? I'm sorry? Have you thought about using dedicated stents in particular in this case using triton stents? Because it's almost like having less metal in the left main, right? To be honest, I don't have any experience about the dedicated stand. Try to understand. You suggest the main branches circumflex stand for the fighting the circumflex and then that gives you opening to the Led. It becomes almost like a culot part without having to put more metal in the left main. All right, I think that is another option. However, frankly, I have no experience about that. So up to this point, we have some very interesting data, many kind of two stand technique. You know that currently we use mini Crochet Crochet Gulo technique, T stand tab, any two stand technique we can make a good critical outcome using the IG guided optimization concern. So whatever you choose the two stand technique, even I have no idea. Dedicate to stand is it two stand after the two stand, how big stand area is most important key predators for the good clinical outcomes. And so whatever you choose the two stand cross sectional area is better enough to 5678 in the later we're going to discuss a little more for the circumflex whole steel part, five millimeter scale and edit approximate six polygonable confluent, seven millimeter scales and main distance eight millimeter scan. So we have some 5678 rule for the drilling stand for the good clinical outcome, for the tuition technique for any main digits. Right, okay, so we did you want to just there are some difficulties. Would you show us the previous one? Wiring is quite easy to the Led previous one some difficulties. Right, that one some difficulties cause the sensor with a wire sensor actually we choose the choice PT choice PT wire wires. That is hydrophilic coating wires. I prefer in some cases through the sten stroke. I believe it really is more easier too. So we pass the choice PT wire and then we have dilated 1.25 millimeter balloon for expanded space, ten stress space here and then okay, we are doing the IVs examination for the ready for us. And so we have a more detailed morphology insight from the IBC examination. Right, so frost imagine is to okay, so Piangle, would you really you can see the distant part of the previous tent. And there are lots of instant restrictive plots. You can see that in the nine and 12:00. And this is the mid portion, I think at the lad the diameter is about 2.8. There are some clock almost three five or the meaning is standing spancing is quite good. Right? Right. As many intimate hyperplasia is the core sober just ISR proximal part almost send diameter four and 45. Oh, great. Right. The big proximal very proximal shaft over the main as free of this. Would you show us again that you start part of Led something so we only have some more ideas. All right, stand to the area. Okay, why not? Distal landing area very much intimate hyperplasia. Stand diameter is almost more than two five lumen area is more than at least five millimeter scale or something. All right. That is if you look at media to media vessel sizes, quite big ones, more than three or five. However, sten diameter is real. Okay, there is almost four media to media. The meaning is there is big vessel and previous standing stand expansion is three o, maybe small. However, area concern is quite good, more than 5 mm something. However, still the stand expansion is less than the reference special diameter, right? Okay, stop it. There is a narrowest portion, 25 something. Okay, go ahead. Still, I personally believe still on the expansion part of not related with a small standing areas. However, compared to the media media reference special diameter still mainly stop here there is mainly intimate hyperpros related ISR if we have some ideas oct examination phyves for this ISL reason that may be related with some what do you think? Neo acid scoliosis characteristics inside. However, we have some limitation using the grayscale arguments for that. Okay, go ahead. There's Led. We have many intimate hyperplasia. We didn't too much get the information about the characteristics itself. However, our proximal party expansion is quite good. Okay, so we're going to do so complex. Okay, obvious again. All right, difficulties. However, it's passed. Good luck. All right, that is some proximal circumflex artery size wise c five, almost four. I think it's quite big artery. Right, three o at three oh, and then okay, coming out to the austere part. A small optus mother ability there from the 07:00 is absolutely free of disease. Yes. Okay, that is very much that one. Okay, another wire from the radius. This is main. Okay, would you show us again? Stop. We know that what it is, right, very interesting findings. Okay, that is polynomial big obstacles, modern branches slowly not okay, backward, backward one or two. Backward, little bit further more. Okay, that one. Go ahead. One or two slowly. Big om branches here. Okay, go ahead slowly. That one. Stop it. That is the charged ocean of a circle complex. It's quite big. 12530, right? Yes, big vessel, some digits, minimal digits. However, if you can clearly see that 09:00, there are some wires and Led coming mouse with a circumferential cell part. Those areas we called, we named the polygon confluence. Okay, go ahead. One or two segment there. Okay. All right, that one. So you can clearly see that combining area by circumference hosting pretty much digits. We have already a small balloon allocation maybe related to the mottling density of a gray scalus as may suggest. We can exactly say that. However, some polar will plaque. Okay, go ahead. One or two segment Led wires. We can clearly see that 10:00 and modes with goa two wires. Okay, stop it. That one, right? 11:00, ten, a 11:00 and other wires from the Led and join mouse with a main here and this part. Look at this circumflex whole cell part and arch of plaque over there, right, quite a big one. Three of them pretty much big one and very focal synopsis, very tighter stenosis flag vulnerabilities maybe related with one and okay, go ahead. Okay, that one distal manias. Right. Okay. This concept we want to take a picture again. Yes. And after the separate two rounds from the ad and circumference. Right. So we have lots of more clear information ideas from the IVs examination. In terms of a pestle size is big enough circumflex or cell part, almost three. If you look at Angela finding the very discrete, very much plaque burdens on the circumfix osteo and in terms of Led and Led stented areas, this third part of stent would be a little bit under expansions compared with the reference special diameter and mainly some intimate hyperplasia. Right. So depending on our findings, I think it's quite clear we're going to do three oversized short drilling stand for the circumference osteo. In terms of a technique concern type technique is more easier to perform and decide what do you think the distal part, we need more high pressure. Right. Don't complain with bigger balloon. And then if possible, we want to do the why not cutting balloons. More even plaque breakdown redistribution of a plaque by cutting balloons. I believe that. And however, we cannot demonstrate any small difference between the cutting balloon and plain balloon and the angioplast before any procedure for the islsions. However, still, if you look at some angiographic findings, I prefer cutting balloon for the okay, so Ario color view. So you want to take another picture for that. You can clearly see that the bifurcation area. Okay. So Kudo and audio, that is more tested test. Okay. I think it's more clear for that usually spot of you. Yes. Is it not? For the operators? However, the view is good. I have not a choice. Right, okay. Take a picture here. Okay. That one more clear. Right. Any suggestions to that? I presume you're going to predilate to make sure both sides are quite well predilated. And did you say you're going to use a tap technique? Yes, it is. That is quite easy. You want to try that some cutting balloon first and high pressure inflation and beam branch. And then we want to see what happened. So cutting balloon, two seven five first. Yes. What's your guide cat size? Is that a seven French guide cat? Your guide guiding cat, two seven five, coding balloon. Cutting balloon. A French chalk in guiding caster, a French so still, I prefer the bigger the better. So for the complex enterprise like le main all right. We want to move to the transfer radials low profiles. However, this kind of complex procedures, bifurcation main and I prefer bigger ones. This is something yes. Okay. Right. So we can clearly see that the Led centric legion area, this is I want to see that floral where it is. Okay. Clearly see, we can clearly see that here. Okay, why not? Okay. Six nominal 667275, right? Yes. Right. Cutting one side cutting, and I pull the device out. Actually, I rotate the device believable or not. So I want to make another aspect. Okay, here. Minor ten minute 1012. Okay. One more. Okay. Why not? Inflate there was wires. However, I just do the cutting force more, pull the system out and a little bit more rotate. All right. It's not easy. Rotation can make okay, great. Technically, rotate the balloons, make some, you know, kinking of the two wires in the inside of Kaider, since we don't too much. We didn't k. Just a minute. Okay. Wires or circumference? K. Why not? All right. More smoother rather than expected. Would you measure the distal part of it is three five non compliant. Non compliant. And finally, we're going to do this a little more. This is non compliant balloon for the high pressure inflations after the cutting balloon. We don't have data, but I believe we have a more clear angiographic findings after the evening breakdown in intimate hyperplasia ISR. And then we want to do high pressure inflation based on the IV's findings. We have a lot of ideas, but I want to say that okay, maybe it's here. Yes. Charge digital, right? Yes. 14 is optimal. Why not? So you want to make a little bit folded system out and why not? Inflate 1818, what do you think? 1818 atmosphere 3.6. Okay. So for the proximal Led and the main area, why not? We want to do the why not? 25. 25, all right. High pressure inflation for the Led side. And then you want to see that what happened. Okay. Test press, big changes. So still we have another options. We want to do another drill to stand for the Led and lemon. However, I still believe rest metal may be better and too much metal for another drill to stand for that. And so I just do okay, why not? Okay. What do you say? The lady looks great. So maybe I'm just wondering whether you just don't want to put more metal in the Led and just use drug alerting balloon in the Led and just stand the second flex. Yes, exactly. Right. Exactly what I plan. Right. We are what I plan. And that one, you're going to make a good angiographic outcomes using the cutting balloon and non compliant high pressure inflation and resolve in terms of underexpension of a stent itself. And there's a more bigger stent area. Right. Would you show us spider view, please? Got it. Okay. So we're going to treat the circumflexial part as the next time, as a next step. Okay, good. Take a picture here. Okay. All right. I like it in terms of Led size. It's big enough. Right. So we're going to do I think it's a three five non compliant balloon for the Led and two seven five balloon. Right. Two seven five. Egypt. No, two five. It's okay. Compliant balloon. Yes. We need a more easy okay. Ten is. Okay. So we're going to choose the three o size. What is the shortest one? This is the length of a stand. Shortest one, giants three oh, 1512. Yes. All right. 15 inch. Okay. Yes. Right. This is stock. Okay. All right. This is so complex. We have already dilate one, two, five balloon. So in the this is one two five balloon. 520. Okay. Why not? Inflate inflate eight two 5810. Just a minute. Ten. Is it quite easy? Okay, one more terrible twelve. Okay, no problem. Is there any other indentations? No indentation. All right. So I believe quite easy to pass the stand for this one. Okay. All right, 15. We want to choose a three o based on the I'm finding there's a big one. So three o. Giants alpine. Giants alpine. And length. 15. Right. 15 length. So before okay. Before inflate before deploy the stand for the circumference, we need a C five. We use balloon for the Led. I think it's too depth. All right, 15. Yes, 15. Okay. Not too difficult to pass the stand. Okay. We need another balloon. Right. I know. I place the balloon for the Led side to kind of a safety for the final. So we know the final pretty much kissing balloon inflation. So I prefer this is a used one. There are big win after the collapsed balloons. However, I want to try that. 35. Yes. Three five. Okay, good. And 35. Previously we used the non compliant balloon for the Led, the guided outside osteom. However, ACTUALTY coaxialty is good. Okay, good. Balloon pass is not too difficult. Okay, here we are. And then we want to pull the stem out a little bit in the main side. I think it's too much. I want to just see the floral. Yes. Okay. I don't want to too much. Okay. US, please. Okay. I think it's quite enough. Yes. What do you think? Is it okay? Would you show us? Ariopia? This is Aria. All right. Test, please. Test it. Okay. You can clearly see that proximal part of stand is protruded the main vessels hanging out a little bit. Right. Okay. Yes. I think it's three five. Spite of your gain, spite of your game. Three five is okay. Okay. I'm going to see that more. All right. 1 mm folders out from the side. Too much. Okay. What do you think? Okay, test it's. Okay. Just nominal ten. Okay, good. Okay. Ten is nominal. Okay. Deflate. Deflate. Why not pull the balloon out? And why not? Okay. Actually, we need a non component blown inflation for that. However, the flag characteristics is quite a soft one. The reason length is show very soft plaque and discrete narrowing. And so I would try to just deliver the balloon for the kissing balloon inflation. Right. Okay. One more. 1616. Absolutely. We didn't see any indentations from the stentic side. And then pull the balloon out. Here we are. Okay. And two balloon delivery system. It will be pulled out. This is circumflex, right? Yes. Right. Circumflex further. All right, why not? So you're going to do low pressure six six is cutting off. Okay. After this cutting off dilation is a circumflex osteom and Led two, three. And then this is Led. All right. So finally I will make another. Okay, almost there. Led pulled out. Okay, why not? Inflate six six during the inflation, I pulled out and then pull the whole system out. Just wine. Okay. There is what I did. What I did is kind of a tap technique. Yes. And then okay. Forgot the top job TV. So for the TV treatment, wiring side bench wire is gone. Yes. Okay. Why not? Okay, good. What do you think? It looks good in this view. Should we see another view? All right, so why not? Okay, so as an extra step, the reason why is I like a choice PD. I don't like a choice PD. Sometimes it's not on the control. All right. There's another view here. Great. All right. I like it. It looks so good. Are you going to do okay, you want to do the wire? All right. Finally, we want to do the kiss. However, still, we're going to make another wire for the be careful. Okay, got it. I don't like it. Just stand short, cross the wire, and then do three o compliant non compliance. It doesn't matter. The meaning is expansion is good already, and I think it's compliant is better. Right. Compliance real. And throw your rooting balloon for the Led crystal part first. And then c five. Throw your rooting balloon kissing for 20 seconds. Right. Are you going to the final IVIS to see the final result? Yes, we're going to do that after the through routing balloon. Right. All right. Final IVIS. We prefer another cases. We're going to start in another loom, and we're going to see the interlace. Right. As a very limited time, we want to make more data. Okay. Right. Yes. Okay. Thank you. We're going to move the second level. Several additional work for the final optimization. We did drug eluding balloon for the Led incense risk analysis region using the 3.526 drug Eluding balloon. And then we did final the kitchen balloon dilation using 3.5 and the three point J. Okay. Could you show us the DB balloon? Okay. No. Okay. DB. Okay. We did the DB. And next okay, go ahead. First of finally, did you do ibis? Okay. And we checked the IBUs, the poster side, and the critic. Limited time. Okay. This is a sock. Yes. Circumflex. Yes, this is Circumflex. All right. Look at this. Sten diameter is almost three. The meaning is stand area is almost seven millimeter scale. Right. So we have some color values. Five. And so compared to that, it's big enough. Seven millimeter scale. I don't believe. All right, this is comploin area. It's big enough. Okay. We already checked the left main Led junction. Boom. Boo is there. Good. Okay, start. Okay. Yes. All right. Look at that one. Stand diameter is almost four. Would you check? Okay. This is conjunction. Yes. Okay, great. So for the Led proximal here. All right. Measure that. Measure. Yes. You want to have some confidence in terms of stand diameters and area. All right, why not? There are some still demand intimate hyperprosome. Okay, good. Perfect. Lumen area is almost 8.4. It's great proxy, right? Yes. So meaning it's big enough and drug looting balloon we're going to expect it's quite clinical outcomes in terms of standing area is the most important product for long term clinical outcome. Okay. We will check the final angel. Okay, shoot. Okay, great. And then audio coder. So great. Okay, final shot. That's great. Yes. So Dr. Good job. So what do you think? Looks excellent. Result. Very nicely done. Almost looks so this is first cases. Maybe we don't have enough time. If you want to show second cases, Dr. Bark okay, why not move to yes, this is an ISR case main bifurcation. If you see the balloon response is not favorable for the DB. So if you have to do another separate stenting, what will be the your most preferred strategy for the poor response to binomial endoplasty for the second, another stenting strategy. What is your preference? The cul load or another what will be to steal? All right. We don't have any solid answer for the ISL cases DB and another drilling stand. So now we are conducting almost 80% patient enrollment is conducting randomized study with a degrading balloon versus another Zion stand for Islam. So you're going to have a semantic in the near future. And still I believe too much metal is not so good rather than less metals. In a practical point of view, I prefer the DB rather than another religion stamp. Yes. My focus to question is if we cannot apply TB alone, that is the trouble. So my personal view, the most predator side of recurrence is a circumflex astrial area. So in the case I second stage, I'm preferred to do the Curlow stenting to save. This ISI in the left circumflex astrial area. But we don't have data. So main to soccer and another curl of tenting is my most preselection strategy in case of failure to balloon. Good. However, I don't believe any difference in terms of whatever you choose the two stand technique anyway, certain situations followed would be more useful beneficial, helpful for some region subset. However, result concrete outcome concern even many mini crochet decay crochets and the cola taste, I don't believe it too much any difference concern. Thanks


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