Angulated views in coronary

angiography
An Indroductory lecture for cath lab technicians

Dr Awadhesh Kumar Sharma

MD(Gold Medalist),DM Cardiology
Dr Awadhesh Kumar Sharma
 Dr. Awadhesh Kumar Sharma is a young, diligent and dynamic interventional cardiologist. He did
his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB
Medical college Jhansi. Then he did his superspecilization degree DM in Cardiology from PGIMER
& DR Ram Manohar Lohia Hospital New Delhi. He had excellent academic record with Gold
medal in MBBS,MD and first class in DM. He was also awarded chief ministers medal in 2009 for
his academic excellence by former chief minister of UP Hon. Mayawati in 2009.He is also receiver
of GEMS international award. He had many national & international publications. He had special
interest in both invasive & non invasive cardiology. He had performed more then 5000 invasive
cardiac intervention procedures successfully till date including coronary angiography, simple &
complex angioplasty, peripheral vessels angiography & angioplasty, carotid angiography &
angioplasty, ASD ,PDA device closures, Mitral & pulmonary valvotomy. He is also in editorial board
of many national & international journal- Journal of clinical medicine & research(JCMR),Clinical
cardiology update, EC Pulmonology and Respiratory Medicine. He is also active member of
reviewer board of many journals. He is also international associate fellow of American college of
cardiology. He is active member of many professional bodies including Indian Medical Association,
Cardiological Society of India, APVIC, ICC, API. He had worked in NABH Approved Gracian
Superspeciality Hospital Mohali as Consultant Cardiologist since 2014-2016. Currently he is
working as Assistant Professor of cardiology at LPS Institute of Cardiology, GSVM Medical college,
Kanpur(UP)under Govt of UP.
Cineangiographic equipments
 A Generator
 X Ray tube – under the patients table
 Image Intensifier- attached to a positioner such as
C-arm, over the patients table
 Optical system
 Digital convertor
 TV monitors
 Control Unit
Cranial View- image intensifier is tilted towards the
head of the patient
Caudal View- image intensifier is tilted down
toward the feet of the patient
AP View – image intensifier is in central position
Lateral View – image intensifier is on left side of the
patient horizontally at body level
Impor tance of angulated
views
 Proper delineation of coronary & peripheral
vascular anatomy
 Origin & course of vessel
 Eccentric lesion
 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
LAO view RIGHT
Cranial view

Catheter and Catheter at

PA view Diaphragm
spine to the RAO view the
shadow
LEFT CENTER
Caudal view
Caudal
view
No diaphragm No diaphragm
shadow shadow
 Standard Angiographic Views
Left Coronary Artery

RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal

 Best for visualizing-
 Left main bifurcation
 Proximal LAD
 Proximal to mid LCx
 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 Knowledge of the orientation of the artery
proximal LAD and LCx for a given view can help identify the
probable path of the artery in the setting of
complete occlusion
Lef t Coronar y Ar ter y
 LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial
Best for visualizing
 Mid and distal LAD
 Distal LCx in a left dominant system
 Separates out the septals from the diagonals
 Standard Angiographic Views
Left Coronary Artery
LM LCx

LCx
LM

LAD

LAD Diagonal
Septals
Diagonal

Septals

Distal
Distal LAD
LAD

LAO 50 Cranial 30
PA 0 Cranial 30 Best for visualization of proximal and
Best for visualization of LM mid LAD and splaying of the septals
proximal and mid LAD from the diagonals. Also ideal for
visualization of distal LCx
Lef t Coronar y Ar ter y
 PA-Cranial view: 00 lateral and 300 cranial

 Best for visualizing -

 Mid LAD
 Distal LAD
Lef t Coronar y Ar ter y
 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
Lef t Coronar y Ar ter y
LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal
Best for visualizing-
 Left main,
 Proximal LAD
 Proximal LCx
 Spider view
 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 Best for visualization of LM
bifurcation and proximal bifurcation, proximal LAD and LCx
LAD and LCx and OM
Lef t Coronar y Ar ter y
PA-Caudal view: 00 lateral and 200 to 300 caudal
Best for visualizing
 Distal left main bifurcation
 Proximal LAD
 Proximal to mid LCx
Lef t Coronar y Ar ter y
PA projection: 00 lateral and 00 cranio-caudal
Best for visualizing
 Ostium of the left main
Left Coronary Artery
Left lateral view:
Best for visualizing
Proximal LCx,
Proximal and distal LAD
Also good for visualizing LIMA to LAD anastomotic site
 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
 Left lateral view: Left Lateral 900
 Ostium of the RCA

 Midportion of the RCA

 Separation of RCA with its RV branches

 Standard Angiographic Views
Right Coronary Artery
Proximal
RCA Proximal
RCA

Mid Distal PDA

Mid RCA RCA
Mid RCA
RCA

PDA PDA/
Distal
RCA PLV

LAO 30 RAO 30 PA 0 Cranial 30

Best for visualization of Best for visualization of mid Best for visualization of distal
ostial and proximal RCA RCA and PDA RCA and its bifurcation
 RAO and LAO
Ventriculography:

RAO Ventricle  LAO Ventricle

Lef t Ventriculogram
Systolic View
RAO
Lef t Ventriculogram
Diastolic View
RAO
Cerebral circulation
 AP View- Common carotid,External carotid,

Internal carotid,Vertebral arteries

 Lateral View- Bifurcation of Common carotid

artery into External carotid & Internal carotid

artery
Commonly used angiographic
views
 Most favorable angulation for iliac angiography is the
contralateral oblique angle, generally 30 to 40 °
 The optimal view for the common femoral bifurcation is 30
to 45° of ipsilateral oblique angulation
 SFA can be imaged in an anteroposterior view with the
addition of an oblique angle if a stenosis is suspected.
 The popliteal artery, tibeoperoneal trunk, and trifurcation
LAO 30
are best imaged in an ipsilateral oblique angle (30°).
 Infrapopliteal runoff can be performed in either an
anteroposterior or an ipsilateral oblique projection

N Engl J Med. 2006;354:379 –386

Vasc Endovascular Surg. 2002;36:439–445