Coronary angiographic views- Elias Hanna

Elias Hanna・2 minutes read

Caudal views are ideal for the left main, proximal LED, and proximal circumflex, while cranial views are better for mid to distal LED and diagonal branching points. Differentiating between branches like LED and diagonal can be challenging, but adjusting views can improve clarity for imaging.

Insights

  • Adjusting views is crucial for optimal clarity in imaging; shifting to more cranial angles can enhance visualization of the LED, while inspiration can aid in improving vertical heart positioning for clearer images.
  • Distinguishing between true septal branches and diagonal branches is essential; the former remains straight during systole, whereas the latter exhibit torquing and shrinking behavior, impacting accurate diagnosis and treatment planning.

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Recent questions

  • What are the ideal views for visualizing the left main artery?

    Caudal views are ideal for distal left main, proximal LED, proximal circumflex; cranial views for mid to distal LED, diagonal branching points.

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Summary

00:00

"Cardiac Views: Tips for Fellow Training"

  • Basic geographic views talk for first-year fellows, also beneficial for higher-level fellows.
  • Caudal views ideal for distal left main, proximal LED, proximal circumflex; cranial views for mid to distal LED, diagonal branching points.
  • Left main, proximal LED, proximal circumflex well shown in caudal views, not in cranial views.
  • Rule for overlap: left circumflex moves with image intensifier, LED and diagonal move opposite; adjust angle to open area better.
  • Arteries on cardiac silhouette border generally not LED, usually diagonal or OM.
  • Foreshortening: lesion visibility best when orthogonal to view, not in line with segment; dense contrast indicates foreshortening.
  • Caudal view shows diaphragm over cardiac silhouette, cranial view shows diaphragm below it.
  • Differentiate LAO from RAO using spine and catheter tip placement with open arms; ribs direction helpful in RAO views.
  • RAO looks into AV groove, LAO into septum; useful for identifying fistula drainage location.
  • Reocadon view good for distal left main, proximal LED, whole circumflex; best for apical LED.

17:58

Optimal Cardiac Views for Clear Imaging

  • The sark is great for the shark up to a point, but for a dominant shark, it loses clarity.
  • The ap color view shows the distal left main bifurcation clearly, while the proximal led and diagonal branching points are not well visualized.
  • The diaphragm in the cardiac silhouette should be at the bottom, not in the middle, for a proper caudal view.
  • The leo caudal view, known as the spider view, is excellent for the distal left main, proximal led, left circumflex, and diagonal and om branches.
  • Position the catheter in the center of the cardiac silhouette for optimal imaging in the leo caudal view.
  • Caudal views are ideal for horizontal hearts, providing a clear view of the left main bifurcation, while vertical hearts are better suited for cranial views.
  • The ap cranial view is recommended for visualizing the mid to distal led, diagonal branching points, and left main ostium.
  • The leo cranial view is excellent for showing the diagonal septal branching points and determining if the led is occluded.
  • In the leo cranial view, the led is parallel to the spine, while the left circumflex is in the av groove, making it ideal for dominant left circumflex cases.
  • Practice adjusting views to improve clarity, such as going more cranial to pull the led down or using inspiration to make the heart more vertical for better imaging.

35:10

Heart shadow branches and radiography views explained.

  • The heart shadow displays various features, including septal and diagonal branches.
  • Distinguishing between branches like led and diagonal can be challenging due to similarities in appearance.
  • Led branches provide true septals that remain straight in systole, unlike diagonal branches that torque and shrink.
  • Diagonal branches can mimic septals but exhibit different behavior during heart motion.
  • Different views in radiography, like eleocranial, offer varying radiation exposure to operators.
  • In obese patients, shallow angles are preferred during imaging to reduce blurriness and radiation exposure.
  • Specific views, like lao and ap cranial, are crucial for imaging the left main artery accurately.
  • For the right coronary artery, views like alliostrate and allio cranial are essential for visualizing branching points.
  • Recognizing features like two bands in the RCA and the crux helps identify the true dominant RCA.
  • Additional views, such as reo, provide supplementary information on the mid-RCA and its branching points.

51:26

Essential Views for Coronary Artery Grafting Techniques

  • Audio view is essential for identifying the mid-RCA and its branches, such as the PDA and acute marginal branches.
  • In an audio view, the true RCA is distinguished from other branches like acute marginal branches.
  • REO view aids in identifying the AV groove and ventricles, crucial for determining branches like atrial or sinus node branches.
  • Illustration of an RCA injection in an LEO view helps differentiate between true RCA, acute marginal, and PDA branches.
  • Different views like LEO, REO, and AP cranial are crucial for imaging vein grafts to various arteries like RCA, diagonal, and OM.
  • Specific views like LEO cranial are optimal for engaging grafts to the RCA, while REO is better for grafts to the OM.
  • Sequential and split grafts are special types with distinct anastomosis configurations, impacting imaging and engagement techniques.
  • For imaging LIMA grafts, views used for engagement and native vessel visualization are crucial, with the left lateral view being traditionally vital for anastomosis assessment.
  • In challenging cases, alternative views like AP cranial or audio cranial can aid in visualizing LIMA to LAD anastomosis, avoiding the cumbersome left lateral view.
  • Proper identification of graft types and engagement sites is facilitated by referencing engagement in straight views and using landmarks like ribs or sternal wires.

01:08:06

Optimal Views for Anastomosis Visualization

  • Use cranial views for the LED, but if unsuccessful, try an ariel straight view, which often works well to display the anastomosis. The best view for the anastomosis is the left lateral view, but if it's very distal, cranial views may suffice, while for proximal anastomosis, an ariel straight view could be beneficial. Always prioritize viewing the anastomosis, especially using views like reo straight, and do not overlook this crucial step.
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