2. Introduction
Angiography: Visualisation of the vascular bed via X-
ray/MRI with contrast injection
Conventional
CT
MRA
Conventional CAG: Current gold standard
3. History
1927
• Egas Moniz: Cerebral angiography
1929
• Werner Forssmann: Cardiac
catheterisation
1940
• Andre Cournand and Dickinson Richards:
Catheterisation and hemodynamics
4. History
Initial attempts focussed on non
selective contrast injections in
aortic root
Selective injections feared with
risk of ventricular fibrillation
based on animal studies
Transient cardiac arrest with aortic
occlusion with balloon was used to
obtain better quality images
1958: Accidental injection of
contrast in right coronary artery by
Dr. Mason Sones and his associateDr. F. Mason Sones
6. Indications
Established CAD:
To define coronary anatomy and formulate management
plan
Emergent revascularisation in STEMI
To confirm non invasive diagnosis of CAD
Left ventricular dysfunction, ventricular arrhythmias,
ambiguous non invasive test results, out of hospital
cardiac arrest survivors
Pre Surgical evaluation
7. Contraindications
No absolute contraindication
Anemia
Renal dysfunction
Active infection
High bleeding risk
Contrast Allergy
11. Contrast material
High osmolality ionic contrast media:
Not used nowadays
High incidence of adverse events
Low osmolar non ionic contrast agents:
Most commonly used agent
Well tolerated
Iso osmolar non ionic contrast agents
12.
13. Femoral
Most frequently used access site
Ease of access, lesser contrast and radiation exposure,
freedom to upgrade to bigger size sheaths
Need for immobilisation, local site complications:
main drawbacks
16. Radial
No need for immobilisation
Lower rate of local vascular complications
Increasingly being used as primary access site
Slightly higher contrast and radiation exposure with
beginners
Spasm, loops, failure to get access may require switch to
femoral route
21. Angiography techniques
Prior heparinisation
Hemodynamic monitoring (Utmost important)
Always check for pressure damping/ventricularisation
before injection
Beware of air and clots
22. Contrast Injection
Left coronary artery: 6-8ml over 2-3 seconds
Right coronary artery: 4-6ml over 2-3 seconds
Should be adequate to fill the coronary artery completely
without streaming
Excessive contrast injection should be avoided
Cine acquisition (@10fps) should continue till contrast
clears from the system
29. LMCA
Best seen in a shallow LAO
projection with slight caudal
angulation
Cranial angulation to
improve visualization of its
proximal and ostial segments.
Steep LAO caudal (also called
the spider view) lays out the
terminal left main
bifurcation.
Not helpful in the case of a
horizontally positioned heart,
in which situation a steep
RAO caudal view is
substituted.
30. LAD
No single view adequately
depicts the entire course of
the LAD.
The proximal LAD is best
visualized in steep LAO
projections with cranial
angulation, whereas the
middle and distal segments
are better seen in LAO and
RAO views with some caudal
angulation.
The best view for most of the
diagonal arteries, to include
their origin and distal
segments, is usually a steep
LAO (50 degrees) with steep
cranial (50 degrees)
angulation
31. LCX
The LCX is best seen in
caudal projections.
The proximal portion of
the LCX is usually imaged
in the RAO caudal
angulation, which also lays
out the marginal arteries.
An alternative view for the
mid segment of the LCX
and the marginal arteries is
the steep LAO caudal
(spider) view.
33. RCA The proximal segment of the
RCA is best seen in the flat LAO
angulation.
For optimal visualization of the
ostium, a steep (50 degrees)
LAO projection is preferred.
The mid segment of the RCA is
best seen in the LAO and flat
RAO projections.
The crux, or distal RCA, and the
proximal portions of the right
PDA and PLB arteries are best
seen with an AP or slight LAO
projection with 20 to 30 degrees
of cranial angulation.
The middle and distal segments
of the right PDA are best
visualized with a flat RAO
projection.
51. Flow
TIMI grade:
TIMI 0 flow (no perfusion) refers to the absence of any
antegrade flow beyond a coronary occlusion.
TIMI 1 flow (penetration without perfusion) is faint
antegrade coronary flow beyond the occlusion, with
incomplete filling of the distal coronary bed.
TIMI 2 flow (partial reperfusion) is delayed or sluggish
antegrade flow with complete filling of the distal
territory.
TIMI 3 is normal flow which fills the distal coronary bed
completely
53. Coronary anomalies
Anomalous origin
From same sinus
From different sinus
From other coronary artery
Single coronary
Aneurysms
Coronary fistulas
56. Graft Angiography
JR4: Most commonly used for various grafts
Amplatz right, LIMA catheter, dedicated bypass graft
catheters may be needed
Clips at sites of graft may be useful guides
Prior CTA gives valuable information
Root angio with pigtail to identify grafts
59. LV angiography
Not routine nowadays
Pigtail with contrast injection via power injector
Done in RAO 30 to estimate LV function and mitral
regurgitation
Assessment of LVEDP and LV to aorta gradient