Dca Rahul

PanVascular Medicine
DOI 10.1007/978-3-642-37393-0_40-1
# Springer-Verlag Berlin Heidelberg 2014
Diagnostic Coronary Angiography

Rahul Sakhujaa* and Sanjay Gandhib
a
Interventional Cardiology, Wellmont CVA Heart Institute, Kingsport, TN, USA
b
MetroHealth Campus, Case Western Reserve University, Cleveland, OH, USA
Abstract
Diagnostic cardiac catheterization may include many different procedural components such as
hemodynamic assessment, noncoronary angiography, and coronary angiography. This chapter pro-
vides an overview of diagnostic coronary angiography. Diagnostic coronary angiography is the gold
standard for evaluating coronary artery disease. This chapter covers the anatomic and angiographic
assessment of the coronary arteries, describes the rationale for invasive coronary angiography,
identifies the steps necessary for invasively imaging the coronary arteries, and defines the risks
associated with coronary angiography.
Glossary of Terms
Appropriate use criteria Evidenced-based guidelines that review and categorize clinical
(AUC) situations where coronary revascularization is classified as
“appropriate,” “uncertain,” or “inappropriate”.
Arteriovenous (AV) fistulae Iatrogenic communications between artery and vein.
Atrioventricular groove A plane that separates the ventricles from the atria.
Cardiac catheterization Invasive procedure that includes invasive hemodynamic
assessments, coronary angiography, and noncoronary
angiography.
Collateral pathways Precapillary arterial vessels which interconnect coronary arterial
distributions, and in the case of significant stenosis in one coronary
distribution, these vessels are recruited and enlarged to supply an
underperfused territory, thereby reducing myocardial ischemic
burden. They are understood as “natural bypasses.”
Coronary angiography Invasive contrast injection during X-ray imaging to visualize the
coronary arteries.
Coronary anomalies Variations in coronary artery circulation with hemodynamic
significance.
Coronary dominance Determined by the coronary artery that reaches the crux, or
crossover point between the atrioventricular and posterior
interventricular groove.
Coronary sinus Principle venous drainage of the heart that lies external to the left
atrium and empties into the right atrium.
Interventricular groove A plane that transects the ventricular septum, dividing the left
ventricle from the right ventricle.
*Email: rsakhuja@mycva.com
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Left anterior oblique (LAO) Refers to the image intensifier to the left of the patient as if the
observer were looking at the heart from the left side.
Angiographically, the spine is located to the right of the image.
Myocardial “bridging” Phasic systolic compression of a segment of artery that travels
within the myocardium.
Pseudoaneurysm A contained rupture of the artery often from leakage of blood from
a hole in the artery.
Quantitative coronary is a computer-assisted algorithm to analyze digitized images of
angiography (QCA) coronary angiograms and provide quantifiable and reproducible
minimal and reference diameters % diameter and area stenosis,
area of atherosclerotic plaque, stenosis geometry, stenosis length,
and eccentricity index. It is a commonly used research tool.
Right anterior oblique Refers to the image intensifier to the right of the patient as if the
(RAO) observer were looking at the heart from the right side.
Angiographically, the spine is located to the left of the image.
Seldinger technique Described in 1953, whereby the anterior and posterior walls of the
artery were punctured and the needle was withdrawn until free
blood return was established. The modified Seldinger technique is
a more contemporary approach of puncturing only the anterior
wall with the needle to gain access to the artery or “front-wall
puncture.”
Sinus of Valsalva Supravalvular anatomic dilation of the aorta from which the
coronary arteries arise.
SYNTAX score The Synergy between PCI with Taxus and Cardiac Surgery
(SYNTAX) score is a lesion-based angiographic scoring system
that was introduced as a tool for grading the complexity of
coronary artery disease prior to randomizing patients to coronary
artery bypass grafting or percutaneous coronary intervention.
TIMI flow Semiquantitative angiographic assessment of coronary perfusion
described in Table 9, abbreviated for Thrombolysis in Myocardial
Infarction (TIMI).
Overview
Diagnostic cardiac catheterization may include many different procedural components such as
hemodynamic assessment, noncoronary angiography, and coronary angiography. Hemodynamic
assessment is often to evaluate structural/valvular disease, pulmonary hypertension, cardiomyopa-
thy, or as an adjunctive evaluation of coronary disease. Noncoronary angiography may involve
alternative vascular or structural angiograms (atrial angiograms, ventricular angiograms, aortic
angiograms, coronary sinus angiogram, etc.).
This chapter will focus on and provide an overview of diagnostic coronary angiography only. By
the end of this chapter, the reader should understand coronary anatomy both anatomically and
angiographically, describe the rationale for invasive coronary angiography, identify the steps
necessary for invasively imaging the coronary arteries, and define the risks associated with coronary
angiography. Equipment, noninvasive coronary artery assessment, and other invasive diagnostic
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techniques for understanding coronary artery pathology (e.g., fractional flow reserve, intravascular
ultrasound, optical coherence tomography) are covered in separate chapters.
Historical Context
The development of coronary angiography and angioplasty has revolutionized the management of
cardiovascular disease. The concept of catheterization dates back to bladder catheterizations in 3000
BC among the Egyptians (Mueller and Sanborn 1995). The earliest reported cardiac catheterizations
were in horses by Hales in 1711 using brass pipes via the jugular vein and carotid arteries (Hales
1733). Werner Forssmann was initially shunned but ultimately credited with the first human cardiac
catheterization on himself, passing a ureteral catheter via venesection on his own left antecubital
fossa in 1929 (Forssmann 1929). By 1950, Zimmerman et al. and Limon-Lason reported the first
successful retrograde left heart catheterizations in humans (Zimmerman et al. 1950; Limon-Lason
et al. 1950). Around the same time, coronary visualization was described during nonselective
aortography. However, it was not until 1958 that Mason Sones pioneered selective coronary
angiography by circumstance (Sones et al. 1959). On pulling a catheter back from the ventricle
into the aorta, the catheter tip selectively engaged the right coronary ostium. Before he could pull the
catheter out, 40 cc of contrast was injected. The patient developed asystole, but survived
(Mueller and Sanborn 1995). Thereafter, Sones developed specially shaped catheters and developed
the technique of selective coronary angiography. Between 1966–1968, Judkins, Amplatz,
Schoonmaker, and King all devised catheters and techniques for percutaneous coronary angiogra-
phy that remain in common practice today (Judkins 1967; Wilson et al. 1967; Schoonmaker and
King 1974).
Since then, techniques have been perfected, with miniaturization and improvement of catheter
and interventional technologies, expansion of access sites, and strategies to minimize complications.
Diagnostic coronary angiography led to Gruentzig and Myler’s introduction of human transluminal
coronary angioplasty in 1977, the birth of interventional cardiology (Gruentzig et al. 1977). To date,
selective coronary angiography remains the gold standard for defining epicardial coronary anatomy.
Normal Coronary Anatomy

Aortic Root Anatomy
Understanding the aortic root is important for understanding coronary anatomy and performing
coronary angiography. The aortic root is the supravalvular outlet of the left ventricle. It lies posterior
and to the right of the pulmonary artery. It most commonly consists of three sinuses
(of Valsalva) – left, right, and noncoronary. Topographically, these sinuses are located left, right
anterior, and right posterior, respectively (Fig. 1). The sinuses of Valsalva are defined by their
topographical location and not by the originating coronary artery. Coronary arteries are defined by
the myocardial territory they subtend, and not from their origin. However, most commonly, the left
coronary artery originates from the left coronary sinus (20 10 posterior to the frontal plane), and
the right coronary artery originates from the right coronary sinus (35 10 right of the sagittal
plane) (Anderson 2000). This becomes important when discussing anomalous coronary anatomy.
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a b
Ascending
Aorta MV
TV
LCA
LC
LCA
LC
RCA
NC
RC
NC
PA
RCA
RC
Fig. 1 Topographical anatomy of the aortic root anatomy. (a) Aortic root as imaged in the left anterior oblique
(LAO) projection, the usual projection for engaging the coronary arteries. In the LAO projection, the right coronary cusp
(RC) is anterior giving rise to the right coronary artery (RCA), and the left coronary cusp (LC) is opposite giving rise to
the left coronary artery (LCA); the noncoronary cusp (NC) lies posterior and extends more inferior than other two cusps.
(b) Cross section of the heart through the valve plane from above. The aortic valve is posterior and rightward relative to
the pulmonary artery (PA). The RCA originates from the right sinus of Valsalva, which is anterior to the left coronary
artery, which originates from the left sinus of Valsalva. MV mitral valve, TV tricuspid valve (Reproduced with permission
from Dr. Windecker, Panvascular Medicine, 1st edn, Lanzer P (ed) chapter 47, Springer 2002)
Coronary Arteries
Coronary arteries consist of an endothelial layer, tunica media, and tunica adventitia. The
endothelial layer is metabolically active with vasodilatory and anticoagulant properties. The tunica
media contains smooth muscle and elastic tissue. The tunica adventitia is the surrounding connective
tissue structure, which contains the vasa vasorum, or small blood vessels that supply the arterial
wall. Disruption of these layers and these processes can lead to coronary artery stenoses, restenosis
following balloon angioplasty, and/or thrombotic occlusion associated with myocardial infarction.
There are typically two coronary ostia arising from the aortic root, giving rise to the left main
coronary artery and the right coronary artery. The left main ostium lies within the wall of the aorta and,
therefore, may be subject to diseases affecting the aortic wall, such as aortitis (e.g., syphilitic, Takayasu,
radiation induced). Given that the aortic root is angulated in the thorax from right downward posterior
to left upward anterior, the right coronary ostium is commonly anterior but inferior to the left (Fig. 1).
On occasion, the left circumflex branch of the left coronary artery originates from a separate ostium;
and the right coronary conus (or infundibular) branch may have a separate fourth ostium.
The coronary vessels have an epicardial course in two orthogonal planes defined by the fibrous
skeleton of the heart (Fig. 2). The major epicardial coronary arteries are the left coronary artery,
consisting of the left main (LM), left anterior descending (LAD), and left circumflex (LCX)
primarily, and the right coronary artery (RCA). They supply the cardiac myocardium, semilunar
and atrioventricular valves, and variable portions of the aortic and pulmonary trunk (Abrams and
Adams 1969). The RCA and LCX encircle the atrioventricular sulcus between the atria and the
ventricles at the base of the heart. Perpendicular to this plane, the LAD and posterior descending
coronary artery (PDA) form a semicircular loop around the apex. The coronary arterial ring in the
atrioventricular sulcus with its branches creates a crown-like appearance, from which the Latin
name, arteriae coronariae, derives.
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a
Superior vena cava Left pulmonary artery
Left pulmonary veins

Aorta
Left coronary artery
Right atrium
Left circumflex artery
Right coronary
artery
Left marginal artery
Posterior
descending artery Left anterior descending
(or interventricular) artery
Right diagonal branch
marginal artery
Left ventricle
Right ventricle
RAO 30 LAO 60
SN L main
L main OM D
D D RCA CX
SN CX CB
CB S S LAD OM
LAD RV
S
OM
RV S D
AcM D
AcM
PL
PD OM
PL
RCA D
Interventricular plane Atrioventricular

plane
PD
Atrioventricular
plane
Fig. 2 Normal course of epicardial coronary arteries. (a) The left coronary artery originates from the left coronary
cusp as the left main (LM) and runs within the aortic wall and around the right ventricular outflow tract/pulmonary artery
(PA) and gives rise to the left anterior descending (LAD) and left circumflex coronary arteries (LCx). The LAD runs along
the interventricular groove with septal perforators (S) branching vertically into the interventricular septum. The LAD
gives rise to epicardial diagonal branches (D), which perfuse the anterolateral free wall. The LCx courses posteriorly
along the left atrioventricular groove, giving rise to epicardial obtuse marginal branches, which supply the free lateral
wall. The right coronary artery (RCA) takes off anteriorly and inferiorly from the left and courses along the right
atrioventricular groove and gives rise to the first branch to the conus (CB) branch, second to the sinus node (SN) branch,
and then to right ventricular (RV) (or acute marginal, AcM) branches. In the majority of patients, at the crux of the heart
posteriorly, the RCA divides into posterolateral branches (PL) and the posterior descending artery (PD). The PD artery
courses along the posterior interventricular groove, giving rise to septal perforators. (b) The epicardial coronary arteries
form a “ring loop.” The right coronary and left circumflex coronary arteries form a ring within the atrioventricular plane
(discriminated in the LAO projection). The left anterior descending and posterior descending coronary arteries form
a loop around the apex in the interventricular plane (discriminated in the RAO projection) (Reproduced from
Grossman’s Cardiac Catheterization, Angiography, and Intervention, 7th edn, Baim DS (ed) Baltimore, Lippincott
Williams & Wilkins, 2006)
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Left Coronary Artery

Most commonly, the left main coronary artery bifurcates into the left anterior descending and left
circumflex coronary arteries. In 20–30 % of people, the LM trifurcates with an additional branch
between these two, named the ramus intermedius. The LM ostium is more conserved, in the
midportion of the left sinus of Valsalva. The left main can measure 3–10 mm in diameter and
0–40 mm in length. In some cases, the left main is very short or absent with separate ostia for the
LAD and LCX. In other cases, the LM can be quite long, in which case, one should be sure that the
LCX does not have an anomalous origin. The LM courses behind the right ventricular outflow tract
and between the pulmonary artery and the left atrial appendage (Fig. 2).
The LAD is a direct continuation of the LM along the anterior interventricular groove. The LAD
supplies 40–60 % of the left ventricular myocardium. The LAD supplies the apex in 70–80 % of
people. Importantly, the LAD and PDA should always form a closed loop around the apex.
Therefore, if the LAD does not reach the apex, then a large posterior descending artery must be
present. A normal variant is the dual LAD, with a proximal division of the artery into two arteries
coursing close to each other. Often, the shorter vessel runs within the proximal interventricular
groove, and the longer vessel runs parallel and joins the mid-distal interventricular groove to the
apex. The primary branches of the LAD are the septal perforators and diagonal branches.
Septal perforators are characterized by a vertical takeoff penetrating the interventricular septum
below. The interventricular septum is 2/3 supplied by septal perforators from the LAD and 1/3 by
septal perforators from the PDA. These septal perforators form important collateral networks
between these territories (Ilia et al. 1991). Septal perforators have gained interest for their role in
certain percutaneous interventions, such as alcohol septal ablation in patients with hypertrophic
cardiomyopathy with left ventricular outflow tract obstruction, as well as for complex retrograde
recanalizations of chronic total occlusions.
Diagonal branches are epicardial branches of the LAD that supply the anterolateral free wall of the
left ventricle. The diagonal branches define the LAD proximal, mid, and distal. The proximal LAD
lies proximal to the first diagonal branch. The mid-LAD lies between the first and third diagonal
branches. The distal LAD represents the segment beyond the third diagonal. These segments have
become standardized (Fig. 3; Scanlon et al. 1999). The caliber of these branches becomes smaller
toward the apical LAD. These vessels run parallel to the ramus intermedius, if present. The larger the
ramus intermedius, the smaller the diagonal branches are.
The LCX artery arises from the LM and courses posteriorly under the left atrial appendage and
continues along the left atrioventricular groove, circumscribing the mitral annulus. The particular
course has gained interest as percutaneous technologies for mitral annuloplasty are being developed;
particular attention must be paid to compromising the left circumflex coronary artery. The first three
branches are termed the obtuse marginal branches, which supply the left lateral free wall. The first
obtuse marginal branch divides the LCX into proximal and distal. All subsequent branches are
termed posterolateral branches, arising from the atrioventricular portion of the left circumflex
(Fig. 3). The left circumflex artery gives rise to the sinus node artery in 40 % of patients
(Kyriakidis et al. 1983). On occasion, the left atrial coronary artery branches early, passing over
the lower and posterior left atrial wall.
The ramus intermedius is present in 20–30 % of people and supplies the anterolateral wall. Its size
and distribution depend on the size of the first diagonal and first obtuse marginal branch. Its size is
often reciprocal to the size of these vessels.
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Fig. 3 SYNTAX scoring system for coronary artery identification. SYNTAX (Synergy between percutaneous
coronary intervention with Taxus and Cardiac Surgery) score is a lesion-based angiographic scoring system. This has
become a more common and validated method from assessing complexity of coronary artery disease when deciding the
optimal strategy for revascularization among cardiologists and cardiac surgeons. Segments are identified as follows:
(1) RCA proximal, (2) RCA mid, (3) RCA distal, (5) Left main, (6) LAD proximal, (7) LAD mid, (8) LAD apical,
(9) First diagonal, (9a) additional first diagonal, (10) second diagonal, (10a) additional second diagonal, (11) proximal
circumflex, (12) intermediate/anterolateral, (12a) obtuse marginal, (12b) obtuse marginal, (13) distal circumflex,
(14) left posterolateral, (14a) left posterolateral, (14b) left posterolateral. In right dominant, (4) posterior descending
from RCA, (16) posterolateral from RCA, (16a) posterolateral from RCA, (16b) posterolateral from RCA,
(16c) posterolateral from RCA; and in left dominant, (15) posterior descending from LCx (Reproduced with permission
from Elsevier from Yadav M et al. (2013) J Am Coll Cardiol 62(14):1219–1230)
Right Coronary Artery

The RCA arises from the right sinus of Valsalva, often inferior to the LCA origin. The ostium within
the sinus is more variable. It courses beneath the right atrial appendage within the atrioventricular
groove to the crux of the heart (Fig. 2). The proximal RCA extends to the vertical portion of the
artery. The proximal portion may be quite tortuous, referred to as a “Shepherd’s crook.” The vertical
segment is the mid-RCA. The distal RCA extends from the end of the vertical segment to the
bifurcation. The first branch is the conus (or infundibular) branch. It provides an important collateral
circle to the proximal LAD, called Vieussens collateral, and in patients with preserved left ventric-
ular function with an occluded LAD, identifying this collateral may be important. This may arise
from a separate ostium in 30–50 % (Angelini 1989). However, one must be careful during invasive
angiography, as forceful injection of contrast into a small conus branch can lead to ventricular
arrhythmias.
The sinus node artery arises from the RCA in 60 %, often as the second branch. In 2–5 %, the sinus
node has dual blood supply (Kyriakidis et al. 1983). The RCA also gives rise to acute marginal
branches, which supply the right ventricle. Often, proximal occlusion of the RCA can create
ischemia in the RV marginal territory with subsequent profound hypotension from right ventricular
ischemia. Acute marginal branches can also supply important collaterals to the LAD or distal RCA.
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Coronary Dominance
The extent and distribution of RCA and LCX are reciprocal, as are the LAD and PDA. That is,
a large distribution of the RCA occurs at the expense of the LCX; similarly, there is reciprocity
between the length and apical termination of the LAD and PDA.
Coronary dominance is determined by the artery that reaches the crux, or crossover point
between the atrioventricular and posterior interventricular groove. This artery gives rise to the
posterior descending coronary artery and atrioventricular nodal artery, supplying the inferior
interventricular septum and the diaphragmatic surface of the ventricle. The term “dominance”
does not refer to size of the respective arteries. The RCA is dominant in 80–85 % of patients, the
LCX in 10 %, and codominant in 5–10 %. In patients with codominant circulation, the PDA will
commonly arise from the RCA and the posterolateral branches from the LCX. Angiographically, the
PDA can be recognized as it gives rise to vertical septal perforators (Fig. 4).
Coronary Veins
The cardiac venous system was long ignored by many cardiologists. Cardiac veins were predom-
inantly visualized during the washout phase of angiography. However, interest in understanding the
cardiac venous system has been growing since the advent of cardiac resynchronization therapy and
with emerging percutaneous therapies to treat mitral regurgitation. The cardiac venous system
consists of the Thebesian and epicardial veins. The Thebesian veins are valveless channels within
the myocardium that empty directly into the myocardium. Angiographically, Thebesian drainage
appears as plumes of contrast entering the ventricle, which must be distinguished from vascular
malformations.
The coronary sinus is the main source of cardiac venous drainage – at least 60 %. Unlike
coronary arterial anatomy, cardiac venous anatomy is highly variable. The coronary sinus lies
external to the left atrium in the atrioventricular groove, just above the left circumflex coronary
artery. The coronary sinus is actually a contractile structure, more akin to a cardiac chamber than
a blood vessel. The contractile nature of the coronary sinus is often mistaken for a stricture (Fig. 5).
The coronary sinus drains into the right atrium between the tricuspid valve and the inferior vena cava
(IVC), opening anteriorly toward the tricuspid valve.
Fig. 4 Coronary artery dominance. Coronary artery dominance is defined by perfusion of the inferoposterior
myocardial wall. (a) The right coronary artery (RCA) gives rise to the posterior descending artery (PDA) and is dominant
in 80–85 %. (b) Codominant circulation (5–10 %) occurs when the inferoposterior wall is supplied by both the RCA
(PDA) and left circumflex (LCx) (usually by posterolateral (PLA) branches). (c) Left dominant circulation (10 %) occurs
when the LCx extends to the crux and gives rise to the PDA and atrioventricular (AV) nodal branch (Reproduced with
permission from Dr. Windecker, Panvascular Medicine, 1st edn, Lanzer P (ed) chapter 47, Springer 2002)
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a b
Fig. 5 Coronary sinus (CS) venogram. (a) CS venography from the right anterior oblique projection (RAO). (b) CS
venography from the left anterior oblique projection. The contractile nature of the CS is demonstrated by the black
arrows in panels a and b. (c) The coronary sinus can also be located by awaiting the venous phase during coronary
arteriography. CS (black arrows), great cardiac vein (GCV, red arrow), marginal vein (MV, yellow arrow), middle
cardiac vein (MCV, orange arrow), and posterior cardiac vein (PCV, white arrow), vein of Marshall (blue arrow)
(Courtesy of Dr. Arun Rao, Wellmont CVA Heart Institute, Kingsport, TN)
The great cardiac vein drains into the coronary sinus via the valve of Vieussens. This valve
separates the noncontractile great cardiac vein from the contractile coronary sinus. The valve of
Vieussens is less distensible and can often be exploited for occlusion balloon venography. The great
cardiac vein receives drainage from the anterior interventricular vein, which lies alongside the left
anterior descending and provides the primary venous drainage for the anterior wall. At the base of
the left ventricle, near the ostium of the LAD, the anterior interventricular vein makes a sharp turn
into the atrioventricular groove, forming the great cardiac vein. The great cardiac vein also receives
venous drainage from the posterior interventricular vein, which runs alongside the posterior
descending coronary artery.
The great cardiac vein and coronary sinus encircle the mitral annulus. Many new percutaneous
mitral annuloplasty technologies are attempting to exploit this anatomic relationship. At present,
the most common reason to cannulate and image the coronary sinus is for left ventricular (LV) lead
placement for cardiac resynchronization therapy (CRT), although it remains unclear if targeting left
ventricular lead placement (e.g., lateral, non-apical) improves CRT outcomes (Liu et al. 2013; Dong
et al. 2012).
Imaging the coronary sinus can be performed using balloon occlusion venography or bolus
injection through larger catheters (Fig. 5). The superior vena cava enters the back of the right atrium
and points forward and leftward toward the tricuspid valve. The IVC enters the right atrium at an
upward and backward angle toward the fossa ovalis of the atrial septum. Therefore, the coronary
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sinus can be approached from either the SVC or IVC, but is most easily accessed via a left
subclavian/brachial vein or internal jugular vein via the SVC. Using the tricuspid valve as
a landmark, the anterior-to-posteriorly directed coronary sinus is located posteriorly at the inferior
margin of the right atrium. It can be entered with a curved catheter (e.g., multipurpose or Cobra
catheter from SVC or IVC, or sometimes a Simmons II from IVC) with counterclockwise approach
from the SVC or clockwise approach from the IVC. Ventricular ectopy may signal entering the right
ventricle, whereas atrial ectopy may confirm entering the coronary sinus. In the anterior-posterior
(AP) fluoroscopic projection, a catheter in the coronary sinus lies across the spine, while in the right
anterior oblique (RAO), a catheter would reveal acute angulation with a superior and rightward
orientation. Washout from coronary angiography may help guide locating the coronary sinus
(Dehmer et al. 1986; Fig. 5).
Coronary Angiography
Diagnostic coronary angiography is one of the most common procedures performed in adults at
approximately 1.5 million/year. The types of procedures have expanded beyond hemodynamic right
and left heart catheterizations, coronary angiography, and percutaneous coronary intervention (PCI)
to include an increasing number of endovascular and structural heart disease procedures.
Coronary angiography begins with preprocedural evaluation. Before proceeding to the catheter-
ization laboratory, the operator must assess the patient – symptoms, risk factors, comorbidities,
physical exam, laboratory data, electrocardiogram, and noninvasive studies. In the current era, there
must be clear documentation of an accepted indication for coronary angiography prior to proceed-
ing. The most recent guidelines concerning indications for diagnostic coronary angiography are
derived from the appropriate use criteria (AUC) (Patel et al. 2012).
Indications for Coronary Angiography

Guidelines for diagnostic coronary angiography were last published in 1999; however, they have
been updated in the form of the multisociety 2012 Appropriate Use Criteria for Diagnostic
Catheterization (Scanlon et al. 1999; Patel et al. 2012; Ryan et al. 1993). In this document,
a panel of experts assigned a score to each indication, ultimately categorizing the test as “appropri-
ate,” “uncertain,” or “inappropriate” for each specific indication. The AUC evaluates clinical
scenarios based on anginal class, adequacy of medical therapy, procedure urgency, and presence
and severity of abnormal noninvasive findings.
Table 1 describes the “appropriate” uses of diagnostic coronary angiography according to this
panel. In general, patients with definite or suspected acute coronary syndromes, symptomatic
patients with intermediate or high-risk or equivocal/discordant noninvasive findings, or patients
with high-risk noninvasive findings associated with poor prognosis independent of symptoms were
rated as appropriate for coronary angiography.
Patient and Operator Preparation

Patient preparation is crucial for a successful procedure. Patient preparation should crystallize the
clinical question that needs to be addressed. Prior coronary artery bypass grafting anatomy should be
clarified to save time, contrast, and minimize risk. In addition, the patient history should confirm
medication compliance, identify relevant allergies, and uncover any bleeding history or planned
surgeries that would complicate anticoagulation/antiplatelet therapy.
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Table 1 “Appropriate” indications for diagnostic catheterizationa

Suspected acute coronary syndrome
Cardiogenic shock due to suspected acute coronary syndrome (ACS)
ST elevation myocardial infarction (STEMI) or suspected STEMI
Unstable angina/non-STEMI (NSTEMI) with low-/intermediate-/high-risk score (e.g., TIMI, GRACE)
Suspected ACS with newly diagnosed left ventricular (LV) wall motion abnormality or newly diagnosed resting
myocardial perfusion defect with low-/intermediate-/high-risk score (e.g., TIMI, GRACE)
Suspected coronary artery disease (CAD): no prior noninvasive stress imaging (no prior PCI, CABG, angiogram
showing 50 % angiographic stenosis)
High pretest probability
Symptomatic
Suspected CAD: prior noninvasive testing (no prior PCI, CABG, or angiogram showing 50 % angiographic
stenosis)
ECG stress testing
High-risk findings (e.g., Duke treadmill score 11) with or without symptoms
Other high-risk findings (ST-segment elevation, hypotension with exercise, ventricular tachycardia, prolonged
ST-segment depression) with or without symptoms
Stress testing with imaging
Intermediate-risk findings (e.g., 5–10 % ischemic myocardium on stress SPECT myocardial perfusion imaging (MPI)
or stress positron emission tomography (PET), stress-induced wall motion abnormality in two or more segments on
stress echo or stress cardiac magnetic resonance (CMR)) with symptoms
High-risk findings (e.g., >10 % ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall
motion abnormality in two or more segments on stress echo or stress CMR) with or without symptoms
Other high-risk findings (e.g., TID, significant stress-induced LV dysfunction) with or without symptoms
Discordant findings (e.g., low-risk prior imaging with ongoing symptoms consistent with ischemic equivalent;
low-risk stress imaging with high-risk stress ECG or stress-induced typical angina); symptomatic
Equivocal/uninterpretable findings (e.g., perfusion defect versus attenuation artifact, uninterpretable stress imaging)
with symptoms
Baseline resting LV dysfunction (i.e., LVEF 40 %) and
Evidence of myocardial viability in dysfunctional segment (e.g., PET, CMR, delayed thallium uptake, dobutamine
echo) with or without symptoms
Echocardiography
Newly recognized LV systolic dysfunction (i.e., LVEF 49 %) with unknown etiology with symptoms
New regional wall motion abnormality with normal LV systolic function with symptoms
Suspected significant ischemic complication related to CAD (e.g., ischemic mitral regurgitation or VSD)
Coronary CTA
Lesion 50 % non-left main with symptoms
Lesion 50 % left main with symptoms
Lesions 50 % in more than 1 coronary territory with symptoms
Lesion of unclear severity, possibly obstructive (non-left main) with symptoms
Lesion of unclear severity, possibly obstructive (left main) with or without symptoms
Patients with Known Obstructive CAD (e.g. Prior MI, Prior PCI, Prior CABG, or Obstructive Disease on
Invasive Angiography)
Medically managed patients
Intermediate-risk noninvasive findings with worsening or limiting symptoms and worsening findings
High-risk noninvasive findings with no/controlled/unchanged OR worsening symptoms or findings
Post-revascularization
Intermediate-risk or high-risk noninvasive findings with worsening or limiting symptoms
(continued)
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Table 1 (continued)
Arrhythmias
Resuscitated cardiac arrest with return of spontaneous circulation with etiology unclear after initial evaluation
VF or sustained VT with or without symptoms, with etiology unclear after initial evaluation
Valvular disease
Preoperative assessment before valvular surgery
Pulmonary hypertension out of proportion to the severity of valvular disease
LV dysfunction out of proportion to the severity of valvular disease
Chronic native or prosthetic valve disease symptomatic related to valvular disease
Noninvasive imaging for valvular disease conflicting with clinical impression of severity in:
Mitral stenosis (mild or moderate, severe)
Mitral regurgitation (mild or moderate, severe)
Aortic stenosis (mild or moderate, severe)
Aortic regurgitation (mild or moderate, severe)
Acute moderate or severe mitral or aortic regurgitation
Equivocal aortic stenosis/low-gradient aortic stenosis (may include pharmacologic challenge, e.g., dobutamine)
Pericardial diseases
Suspected pericardial tamponade
Suspected or clinical uncertainty between constrictive versus restrictive physiology
Cardiomyopathies
Known or suspected cardiomyopathy with or without heart failure
Reevaluation of known cardiomyopathy with change in clinical status, exam, or to guide therapy
Pulmonary hypertension or intracardiac shunt evaluation
Known or suspected intracardiac shunt with indeterminate shunt anatomy or shunt fraction
Suspected pulmonary artery hypertension with equivocal/borderline or elevated right ventricular systolic pressure on
resting echo study
Resting pulmonary hypertension, to determine response to pulmonary vasodilators or response after initiation of drug
therapy
Post-heart transplant patient with or without performance of endomyocardial biopsy
Indeterminate intravascular volume status with unclear etiology after initial evaluation
a
Includes hemodynamic assessment in addition to diagnostic coronary angiography (Adapted from Patel et al. (2012))
Aspirin should be continued throughout the periprocedural period in case of ad hoc PCI. In
addition, in patients with high suspicion of needing percutaneous intervention and low risk of
bleeding or surgery, one may consider pretreating with clopidogrel for diagnostic coronary angiog-
raphy; however, there seems to be less need to pretreat patients with newer antiplatelet agents given
their rapid time to onset (Bellemain-Appaix et al. 2012; Montalescot et al. 2013).
On the other hand, certain medications should be withheld prior to angiography. In patients with
diabetes, the insulin dose is usually halved the night before and held the day of the procedure.
Metformin is held for 24–48 h before and after angiography to prevent lactic acidosis if renal failure
develops. In patients at higher risk, consider restarting metformin when renal function is confirmed
to be stable. Common anticoagulants might be managed as per Table 2.
Patients are often given conscious sedation – usually a combination of narcotic and anxiolytic. In
patients who are expected to receive anxiolytic, restricting oral intake for at least 4 h is suggested
(Bashore et al. 2012). Patients with prior reaction to contrast media should receive steroid and
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Table 2 Management of anticoagulants for diagnostic coronary angiography

Warfarin Hold at least 3 days prior to procedure. Check INR prior to procedure. Consider proceeding
with radial artery access INR <2.2; femoral artery access INR <1.8. Consider restarting night
of procedure
Dabigatran For eGFR >50, hold 24 h prior to procedure; for eGFR 31–50, hold 48 h prior; for eGFR <30,
consider holding 4 days prior. Consider restarting night of procedure
Rivaroxaban For eGFR >30, hold 24 h prior to procedure; for eGFR <30, consider holding 48 h prior to
procedure. Consider restarting night of procedure
Apixaban Hold 24 h prior to procedure (since increase signal of stroke when stopped in atrial fibrillation
trials). Consider restarting night of procedure
Unfractionated heparin Hold at least 2 h prior to procedure (PTT <60 or ACT <160 are “normalized”)
Low molecular weight Hold at least 8 h prior to procedure
heparin
Adapted from Fawole et al. (2013)
antihistamine prophylaxis. Current recommendations are prednisone 50 mg 13 h, 7 h, and 1 h prior

or hydrocortisone 200 mg IV 2 h prior with H2 blocker.
Review of recent laboratory data is essential, including beta-hCG for women of childbearing age.
Preprocedural hydration with isotonic saline (1–1.5 ml/kg/h) for 3–12 h before and continuing
6–12 h post procedure after is often helpful in reducing risk of contrast-induced nephropathy (CIN)
in patients at low risk for volume overload (Brar et al. 2008). In patients of concern for volume
overload, a strategy has been published using left ventricular end-diastolic pressure to guide
hydration and minimize CIN and volume overload (Brar 2012). N-acetylcysteine has been shown
to provide no additional benefit (ACT Investigators 2011). CIN will be addressed later in this
chapter.
Operator preparation is also important for successful procedures. Physical examination should
decipher structural heart disease with regard to adjunctive procedures during diagnostic angiography
and should ascertain appropriate access site. Blood pressure should be measured in both arms to
identify possible subclavian stenosis. The only absolute contraindication would be patient refusal.
Table 3 reviews the many relative contraindications to diagnostic angiography which should be
considered.
Once any contraindications have been addressed, procedural risks and alternatives should be
discussed in detail and are covered later in this chapter. Operators should plan their procedure to
minimize risks such as radial approach, smaller sheath sizes, lower radiation doses, and optimal
anticoagulation regimens (i.e., bivalirudin instead of heparin + GP IIb/IIIa inhibitor).
Informed consent must represent a patient’s understanding of risks, benefits, and alternatives, as
well as consent to perform the procedure. It is often worthwhile to involve family in these
discussions when collective decision-making is helpful for patients and/or if decisions during
procedural sedation may be needed. Operators should address all questions raised by the patient
and his/her family during this process.
Finally, before starting the procedure and administering sedation, it is important to perform
a “time out,” to stop and ensure that the patient and all operators agree that the appropriate procedure
is performed on the appropriate patient. At this time, the operator should confirm any allergies and
ensure that appropriate equipment is available in order to facilitate the safe procedure possible.
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Table 3 Contraindications to cardiac catheterization and strategies to address

Absolute contraindications
Refusal to provide informed consent Ensure that risks/benefits/alternatives have been clearly discussed/
understood
Relative contraindications
Inability to provide informed consent Obtain consent from family (unless emergent)
Unable to tolerate/cooperate for procedure Sedate adequately; may need respiratory support
Pregnancy (especially first and second Minimize radiation, abdominal lead shielding; consider radial access
trimester)
Active systemic infection Defer procedure as possible. If necessary to proceed, consider
periprocedural antibiotics and avoiding vascular closure devices with
rapid sheath removal as possible
Decompensated congestive heart failure/ Unless related to active ischemia or condition that requires
respiratory distress catheterization to diagnose, defer procedure for diuresis and
respiratory support as needed
Uncontrolled hypertension Intravenous therapies for hypertension. Consider deferring until
controlled
Uncontrolled coagulopathy or severe Defer procedure or consider radial approach until resolved. In selected
thrombocytopenia patients, consider fresh frozen plasma or platelet transfusion during
sheath removal
Severe anaphylactic reaction to contrast Premedication for contrast allergy (steroids, histamine blockers)
medium (for patients receiving contrast)
Acute or chronic renal failure (for patients Defer procedure until resolved; prehydration and minimize contrast
receiving contract)
Diabetic patients on metformin Hold metformin for 48 h after the procedure; consider waiting to
restart until renal function confirmed to be stable in patients at high
risk for contrast-induced nephropathy
Do not resuscitate code status Consider periprocedural suspension of this status
Adapted from Bangalore S, Kirtane AJ, Dehmer GJ, Kandzari DE, Rao SV, Ziada KM (2013) (eds) CathSAP4.
Table 4 – Relative contraindications to cardiac catheterization and modification strategies, chapter 4.1
Vascular Access Considerations

Vascular access complications are the most common causes of morbidity and prolonged hospital-
ization and, therefore, require particular attention. The predominant strategies for coronary arterial
access are via femoral arterial or radial arterial access and will be the focus of this section. Brachial
arterial access was the initial approach described by Sones for diagnostic coronary angiography, but
has been eclipsed by these other access routes. There are reports of other access sites in uncommon
situations (e.g., ulnar, direct carotid arterial access). Outside of diagnostic coronary angiography,
with increasing endovascular and structural heart disease, other arterial access sites are more
prevalent (e.g., subclavian, direct aortic, popliteal, tibial), yet remain less relevant for diagnostic
coronary angiography.
Femoral Access
Percutaneous coronary angiography remains most commonly performed via retrograde common
femoral arterial (CFA) access (Feldman et al. 2013). The CFA offers advantages for arterial access.
Its large size allows for large-sized sheath access, particularly for aortic and structural heart disease
procedures. In addition, its superficial course and predictable location over the femoral head render it
a reliable access site.
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a
Anterior
superior
iliac spine
Femoral
artery
Femoral
vein
Inguinal
ligament
Symphysis
pubis
Fig. 6 “Target zone” for femoral arterial access. (a) The “target zone” for femoral access is over the inferior 1/2–1/3
of the femoral head (denoted by yellow dashed lines and arrows), in the common femoral artery (red arrow), above the
bifurcation of the superficial femoral artery (green) and profunda femoris arteries (orange), and below the inguinal
ligament (estimated by the blue line), above which is the external iliac artery (white arrow). The inferior epigastric artery
(purple) often wraps the inguinal ligament and provides a marker for its location; the ideal puncture site is below the
inferior margin of the inguinal ligament. (b) This demonstrates the needle (dashed arrow) entering the femoral artery at
the appropriate site (solid black arrow) and a J-wire (dotted arrow) being advanced. The common femoral artery is
visibly calcified in this patient (variable dashed arrow). Angiograms courtesy of Wellmont CVA Heart Institute,
Kingsport, TN (Schematic reproduced with permission from Dr. Windecker, Panvascular Medicine, 1st edn,
Lanzer P (ed) chapter 47, Springer 2002)
Access Technique
The goal of retrograde CFA access is a front-wall puncture below the inguinal ligament but above the
bifurcation of the common femoral artery into the superficial femoral artery (SFA) and profunda
femoris artery. Figure 6 demonstrates the “target zone” for arterial access over the inferomedial
femoral head. The inguinal ligament can be palpated. The inferior margin of the femoral head can be
localized using a metal clamp over the skin under fluoroscopy. This identifies the skin entry site with
the goal of puncturing the artery 1–2 cm more cephalad with an entry angle of 45–60 . The inguinal
skin crease is variable and, therefore, should not be used as a reliable marker for the femoral head or
puncture site. It is often caudal to the true bifurcation, especially in obese patients (Lechner
et al. 1988).
Local anesthesia – often 1 % lidocaine – is given at the site of needle entry. Other local anesthetics
may be used in patients with documented allergy to lidocaine, for example, benzocaine, xylocaine,
or marcaine. In the rare instance of cross-reactive allergic reaction to all local anesthetics, 1 %
diphenhydramine has been demonstrated to be a safe and effective alternative (Ernst et al. 1993).
The traditional Seldinger technique, described in 1953, whereby the anterior and posterior walls
of the artery were punctured and the needle was withdrawn until free blood return was established,
has been modified (“modified Seldinger technique” or “front-wall puncture”) to the more contem-
porary approach of puncturing only the anterior wall, in an effort to reduce bleeding associated with
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the potent antiplatelet and antithrombotic agents used today (Seldinger 1953). Fluoroscopy can be
used to guide needle puncture, but is not necessary. If there is resistance to advancing the wire, do not
advance. Rather, remove the wire, often decrease the needle entry angle into the artery until adequate
blood returns, and reattempt wire passage. If this proves insufficient, rotate the needle to exclude
possible apposition against the wall. Then, advance the needle slightly to ensure adequate penetra-
tion of the anterior wall. Finally, slowly withdraw the needle in case of inadvertent back-wall
puncture.
Ultrasound-guided arterial access is becoming more widespread. The FAUST (Femoral Arterial
Access with Ultrasound Trial) multicenter trial demonstrated that real-time ultrasound use reduced
the number of attempts, time to arterial access, and vascular access complications (Seto et al. 2010).
Fluoroscopy may also be helpful in locating the needle tip relative to vascular calcifications or the
femoral head.
In addition, micropuncture techniques with 21 gauge needles, popularized by radial arterial
access, are increasingly used during femoral access. While less traumatic with regard to the
arteriotomy and in the case of multiple passes to gain access, the blood return and tactile feel of
wire passage through smaller needle lumen require experience; otherwise, arterial dissections or
subcutaneous wire fractures may be more common among less experienced operators. Alternatively,
Doppler-tipped needles may be utilized to localize the artery.
Once wire position is confirmed, the needle is removed, the sheath is advanced, the internal dilator
is removed, the sheath is flushed, and the guidewire is cleaned.
Pitfalls to Femoral Arterial Access: Peripheral Arterial Disease, Ability to Lie Flat
Complications to vascular access and diagnostic coronary angiography will be addressed later in this
chapter. However, the largest pitfall to common femoral arterial access is peripheral arterial disease.
The artery should be easily palpable, especially when anticipating the possible use of larger sheaths
for intervention or adjunctive devices, such as an intra-aortic balloon pump. Symptoms attributable
to aortoiliac steno-occlusive disease or an abnormal peripheral vascular exam should trigger
consideration of alternative access sites as appropriate or further evaluation of peripheral vascular
disease prior to, or as part of, common femoral arterial access. As above, ultrasound can assist in this
assessment, but only among operators with significant facility with use and interpretation of
ultrasound findings. Prior to obtaining access, the operator should assess pulse strength and location,
presence of a bruit, distal pulses, and stigmata of aortoiliac atheroembolism (e.g., abdominal bruit,
peripheral livedo reticularis).
Moreover, whether vascular closure devices are used or not, patients with femoral arterial access
must lie flat during the procedure and continue with the head of their bed <30 until adequate
hemostasis is achieved. It may be helpful to have certain patients lie flat for hours prior to the
procedure to ensure the patient will tolerate it.
Catheter Advancement
The catheters are generally advanced over a 0.03500 guidewires. It is helpful to follow the wire under
fluoroscopy to ensure that it passes freely into the abdominal aorta. The wire should lie to the left of
the spine, confirming its intra-arterial course (rather than to the right, which would be more
consistent with the vena cava and venous access).
In patients with an abdominal aortic aneurysm, or in whom it is difficult to advance the wire on
first passage, use of an exchange-length 260 cm 0.03500 wire will maintain access to the aortic root
rather than having to navigate the wire across a difficult aorta on multiple occasions. Another
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strategy is to advance a 45–65 cm sheath into the thoracic aorta, excluding the diseased or
aneurysmal aorta and its potential for causing complications.
Similarly, in patients with peripheral arterial tortuosity or ectasia (often in the iliac, but relevant for
traversing the innominate or subclavian), steerable wires (e.g., Wholey wires) may be helpful to
traverse these segments. Oftentimes, angled catheters (e.g., angled 4 F glide catheters or 4–5 F JR4
diagnostic catheter) may be needed to direct wires and for additional support. If this combination is
unsuccessful, a 0.03500 angled non-stiff glide wire can often navigate the tortuosity. These wires
should be exchanged for stiffer wires (e.g., Supracore (Abbott Vascular, Abbott Park, IL), Amplatz
(Boston Scientific, Natick, MA), or Rosen wire (Cook Medical, Bloomington, IN) prior to inserting
and advancing sheaths or catheters. So as not to navigate these segments on multiple occasions, as
well as to facilitate catheter manipulation without losing torque in these segments, a longer sheath
(23 cm) can be advanced past these segments.
In patients with peripheral arterial disease, the same techniques can be employed as used as for
tortuous segments – using steerable, less traumatic guidewires (Wholey, glide wires) to cross
diseased segments with directable catheters. However, prior to deciding to advance long sheaths
beyond diseased segments, angiography should be considered to identify whether it should be
traversed or treated, or whether alternative access sites should be considered, to reduce the risk of
distal ischemia. Angiographic roadmaps can be used to facilitate navigating such disease. In such
patients, the smallest reasonable sheath diameters should be selected.
Finally, similar techniques are often necessary in patients with postsurgical or scarred groin
access. During access, it is important to create a skin incision and to perform blunt dissection of
a channel to the artery to facilitate sheath passage. Often, use of serially larger dilators (e.g., 4 F
sheath dilator alone, then 5 F sheath dilators, then 5 F sheath) over a stiff wire (e.g., Supracore) is
needed to allow the sheath to track. If dilators do not pass or wire appears to kink, often a 4 F 65 cm
glide catheter can be carefully advanced over the wire, to facilitate exchange for a stiffer wire to
support sheath insertion. If the obstruction appears to be from a recent vascular closure device,
another access site may be the safest option. Although some manufactures state that immediate
reaccess is feasible, there are case reports of device disruption or embolization.
Hemostasis
Careful vascular access and preparation are essential for obtaining safe hemostasis. As discussed in
the complications sections, accessing the femoral artery above the inguinal ligament (“high” stick)
increases the risk of retroperitoneal bleeding, and accessing the artery below the SFA and profunda
femoris artery bifurcation (“low” stick) may lead to bleeding with or without pseudoaneurysm
formation. Thus, appropriate initial access within the “target zone” is important. Morbid obesity and
low body mass index, hypertension, advanced age, female gender, thrombocytopenia, and renal
failure increase risk for access site bleeding (Gurm et al. 2002). On one hand, the longer an arterial
sheath remains in place, the greater the risk of bleeding. On the other hand, early removal of a sheath
in a patient receiving procedural anticoagulation increases the bleeding risk.
Prior to removing the sheath, the activated clotting time should be 160 s. The patient should be
stable without hypotension, hypertension, or the possibility of requiring urgent repeat catheteriza-
tion. Pain should be managed with intravenous narcotics such as fentanyl or morphine. Given the
possibility of vasovagal hypotension, continual monitoring of vital signs is important. Atropine and
intravenous fluids should be ready for immediate administration in the case of hypotension.
Often the duration of compression has been suggested for 5 min for each French size of the sheath
and 1 h of subsequent bed rest per French size of the sheath. However, duration of compression can
be variable depending on sheath size, patient habitus, blood pressure, ease of compressibility (e.g.,
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Table 4 Advantages and disadvantages of radial access versus femoral access

Advantages Disadvantages
Easy compression Smaller artery limits sheath size
Distance from adjoining nerve and vein Vascular spasm
Possible with lower extremity peripheral arterial disease Greater learning curve
Collateral circulation via ulnar artery Longer fluoroscopy and procedure time
Lower bleeding risk Radial artery occlusion
Early ambulation and shorter bed rest
Improved patient comfort
calcified vessel), and anticoagulation. It is often best to compress focally over the arteriotomy rather
than with a fist or stack of gauze.
Vascular closure devices have become more common practice for achieving hemostasis and more
rapid patient ambulation. However, the data are confounded and have not consistently supported
improved outcomes versus manual compression (Nikolsky et al. 2004; Sanbone et al. 2010).
It is often advised that patients not lift more than 10 lb for at least 3–5 days, as the Valsalva is
thought to threaten hemostasis.
Radial Access
Radial artery access for coronary angiography is increasingly being used to minimize vascular
complications associated with femoral access. Despite enthusiasm for the adoption of radial arterial
access for coronary angiography, radial artery procedures in the United States have increased from
less than 2 % of total cases to about 8–10 % for coronary diagnostic procedures by most recent
reports (Feldman et al. 2013; Caputo et al. 2011; Rao et al. 2008). This is still low compared to 30 %
procedures done via radial access outside of United States (Dehmer et al. 2012).
The main advantages and disadvantages of radial access compared with femoral access are
outlined in Table 4. While access via ulnar artery has been described (Aptecar et al. 2005), due to
medial and deeper location of ulnar artery and its proximity to the ulnar nerve, radial approach is
generally the preferred upper extremity access.
Prior to radial access, the collateral circulation via the palmar arch is evaluated by using
a modified Allen’s test or Barbeau test. The Barbeau test is performed using a pulse oximeter
attached to the patient’s thumb. Both radial and ulnar arteries are occluded followed by release of
ulnar artery and assessment of the waveform (Fig. 7) (Barbeau et al. 2004). Due to risk for hand
ischemia, radial access should be avoided in patients with an abnormal Barbeau test.
Access Technique
Radial artery access is generally performed 2 cm proximal to the radial styloid process after
infiltration with small amount of local anesthesia. Access can be performed with a modified
Seldinger technique (“front-wall” puncture) with a 21 G needle or true Seldinger (through-and-
through) puncture with an Angiocath followed by slow withdrawal of the Angiocath until brisk
blood return is seen. A 0.01800 or a 0.02100 guidewire is then advanced followed by placement of
a 5 or 6 Fr short or long hydrophilic sheath. Use of hydrophilic sheath has been shown to reduce the
incidence of radial artery spasm though sheath length has no impact on the incidence of radial artery
spasm or procedural success (Rathore et al. 2010).
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Radial Artery Compression

Type Start After 2 min.
Oxymetry Oxymetry
A + +
B + +
C − +
D − −
Fig. 7 Barbeau test. The above illustration demonstrates the morphology of the plethysmography tracing and the
ability of the oximeter to provide a reading of the oxygen saturation (positive oximetry) before, immediately after, and
2 min after radial artery occlusion. The response can be categorized into 1 of 4 types. Patients with type D response
should not undergo transradial catheterization of the wrist (Reproduced with permission from Kanei et al. (2011))
Pitfalls to Radial Arterial Access: Spasm, Radial Loops

Since the radial artery is prone to spasm (Fig. 8), intra-arterial verapamil (3–5 mg) with or without
nitroglycerin is routinely used to minimize spasm. Withdrawing blood from the sheath to mix the
medication with blood alkalinizes the solution and minimizes the discomfort relative to adminis-
tering the medication directly into the artery via the sheath. Local anesthetic, such as 1 % lidocaine,
at the skin entry site and around the artery may reduce spasm. In addition, generous sedation and
systemic analgesia also help to minimize spasm.
Catheter Advancement
The catheters are generally advanced over a 0.03500 J tip guidewire. It can often be helpful to see the
wire traverse the elbow; however, routine fluoroscopy of the wire passage is often only employed if
there is any resistance. The presence of a radial artery loop is sometimes encountered at the level of
forearm (Fig. 9). The loop can usually be traversed with the use of 0.03500 Wholey or glide wire. In
some cases, using 0.01400 coronary guidewires (or two 0.01400 coronary “buddy” wires) can
sometimes help negotiate the loop, as well. In case of any issues advancing catheters or wires,
fluoroscopy or even angiography can help visualize the problem and might facilitate safely advanc-
ing equipment or deciding to abort this access route. Similarly, there can be significant tortuosity in
the brachial, subclavian, and innominate arteries or aberrant takeoff of the right subclavian artery
from aortic arch (Fig. 10) that requires the use of a steerable guidewire. Occasionally, deep
inspiration and rotating the head to the ipsilateral side can facilitate passage into the ascending
aorta. We recommend the use of an exchange-length 0.03500 wire, especially to perform catheter
exchange in patients with any difficulty with initial advancement of wire. In addition to
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Fig. 8 Radial artery spasm. The small caliber of the radial artery with absent flow around the catheter due to
radial artery spasm is demonstrated above (Courtesy of Dr. Sanjay Gandhi, Case-Western Reserve, MetroHealth,
Cleveland, OH)
Fig. 9 Radial artery aberrations. There are variant pathways of the radial artery. (a) Radial artery loops can be
encountered when performing transradial cardiac catheterization. These can be traversed using soft, atraumatic
guidewires or a combination of one or two (“buddy”) 0.01400 wires to straighten the loop. (b) High radial takeoffs
(white arrow) from the brachial artery (black arrow) may alter the course of wires and catheters (Courtesy of Dr. Sanjay
Gandhi, Case-Western Reserve, MetroHealth, Cleveland, OH)
understanding the anatomy and treating spasm, when there is no physical obstruction, advancing
and removing catheters can be facilitated by increasing the lubricity of the artery by injecting the
Rota-Glide™, the same mixture used in rotational atherectomy.
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a b c
Fig. 10 Tortuosity of upper extremity arterial tree. (a) Brachial artery tortuosity, (b) innominate artery tortuosity, or
(c) aberrant right subclavian artery origin (from the left side of the arch in this case) can provide resistance as well and
may require similarly careful navigation as used with radial artery loops (Courtesy of Dr. Sanjay Gandhi, Case-Western
Reserve, MetroHealth, Cleveland, OH)
Hemostasis
Post-procedure the sheath is removed and hemostasis achieved with manual compression. There are
several compression devices, e.g., TR band (Terumo Medical, Somerset, NJ), that can be used for
effective compression. Patent hemostasis – ensuring patent antegrade radial flow using modified
Barbeau test during compression – has been shown to lower the rate of radial artery occlusion.
Administration of anticoagulation (e.g., 50 units/kg or 5,000 units of heparin intravenously) after
establishing radial arterial access as well as use of smaller sheath sizes have also been shown to
reduce the rate of radial arterial occlusion (Pancholy et al. 2008).
Right Versus Left Radial Access

The choice of left versus right radial access is operator dependent. The right radial access allows for
keeping the catheterization laboratories’ usual orientation from the right side. Currently, there are
specialized catheters like the Jackie catheter (Terumo Medical, Somerset, NJ) that allow for
engagement of both right and left coronary arteries via right radial access. Left radial access allows
for the use of traditional femoral catheters for coronary engagement and may be particularly useful in
patients with prior coronary artery bypass surgery as they allow for easier engagement of the left
internal mammary artery. Left radial access may also be preferable for peripheral and renal
angiography due to shorter distance to these vessels.
Brachial Access
While early diagnostic catheterization as initially described by Sones was performed via brachial
artery cutdown, this technique and these catheters are rarely used any longer. With the advent of
radial arterial access, fewer procedures are being done via brachial arterial access. In contemporary
practice, it is more commonly used during peripheral endovascular procedures requiring larger
sheath sizes. For diagnostic coronary angiography, brachial arterial access is not used unless femoral
access is unobtainable due to peripheral arterial disease and radial arterial access is too small for the
necessary sheaths.
The brachial artery is located in the antecubital fossa, medial to the biceps tendon and lateral to
the median nerve. Arterial access just above the antecubital skin crease often facilitates arterial
access just above the bicipital aponeurosis. The more proximal the access site, the more likely the
median nerve can be injured (Ferguson and Kamada 1986).
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a
Dilator Guidewire
Intravascular Sheath
Sidearm
b
Fig. 11 Intravascular sheaths. (a) 4 F intravascular sheath with its dilator in place over a guidewire. After arterial
access is obtained with a needle, the guidewire is introduced, and the sheath is inserted with the dilator in place. The
dilator is removed once the sheath is inserted. The sidearm can be used to inject contrast, draw blood samples, and
transduce intra-arterial pressure. (b) 4 F, 5 F bright tip, 6 F long, and 24 F sheaths are shown for comparison
Often, real-time ultrasound guidance and micropuncture technique are used to minimize time and
attempts at obtaining access. 8 F sheaths can usually be advanced from the brachial artery.
Ultrasound can also be helpful in assessing sizing the artery for appropriate sheaths.
Equipment
Equipment is covered in greater detail in other chapters. Vascular sheaths are used to maintain
vascular access while minimizing vascular trauma. Most sheaths consist of a side port to allow
pressure assessment and flushing with a hemostatic valve to minimize bleeding. The standard adult
sheath is 10–11 cm in length for diagnostic coronary angiography; however, sheaths can range up to
90 cm in length. Longer sheaths (23–45 cm) can provide additional backup support and torque
control for catheter manipulation, which is particularly useful when negotiating very tortuous
peripheral vasculature. Sheaths range from 3 French to greater than 26 French (Fr), with 1 Fr
corresponding to 0.33 mm (Fig. 11; Table 5). The actual French size is usually 1–1.5 F size larger
than the labeled size, as the labeled French size of a sheath refers to the inner diameter. For coronary
angiography, the most common sheaths are 4 F–6 F in diameter.
Guidewires are used to guide sheath and catheter advances and exchanges. For diagnostic
catheterization, most wires are 0.035–0.038 in., ranging from 35 to 260 cm. The longer wires are
used to exchange catheters in the ascending aorta in patients with tortuous iliac arteries, aneurysmal
aortas that were difficult to traverse with initial passage, and often with radial arterial access.
Guidewires are either straight or J tipped. Straight wires are shapeable and steerable and should
have atraumatic tips, while J-tipped wires are favored to prevent retrograde dissections. Despite
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Table 5 Conversion table for French size

French Inches Millimeters
3 0.039 1
4 0.053 1.3
5 0.066 1.7
6 0.079 2
7 0.092 2.3
8 0.105 2.7
9 0.118 3
10 0.131 3.3
coating to reduce friction and thrombogenicity, guidewires are among the most thrombogenic
equipment and should not be kept intravascular for prolonged time periods.
Diagnostic catheters are thinner walled and therefore more flexible than guide catheters.
Catheters are also measured in French sizes. To ensure compatibility with guides, the labeled French
size refers to the outer diameter of the catheter. Smaller French size catheters correspond with
smaller sheath sizes which are less prone to access site bleeding complications, but are more prone to
inadequate vessel opacification (Khoukaz et al. 2001; Kohli et al. 1989). The hub of the catheter
attaches to a manifold and can be rotated to achieve coaxiality of the catheter. The distal end of the
catheter has a primary and a secondary tip that are shaped to cannulate different arteries (Fig. 12).
There are multiple different catheters for engaging native coronary arteries and bypass grafts. Table 6
covers common catheters used for specific coronary arteries or bypass grafts (Casserly and Mes-
senger 2009).
Radial angiography can be easily performed with standard femoral diagnostic catheters including
Judkins left and right catheters from right or left radial access. However, especially from the right
access, JL 3.5 or JR 5 curves may be needed for better engagement. The use of conventional
catheters is, however, limited by necessity for catheter exchanges that may increase the likelihood of
radial artery spasm. There are currently many available universal catheters for engagement of both
right and left coronary arteries, e.g., Kimny (Boston Scientific, Natick, MA); Tiger, Jacky, and Sarah
(Terumo, Somerset, NJ); Sones (Cordis, Warren, NJ); and Barbeau and MAC 30/30 (Medtronic,
Minneapolis, MN) (Fig. 13). While the use of these catheters minimizes the need for catheter
exchange, there is a learning curve for operators to be proficient in their use.
Catheterization Techniques
Judkins Technique
Decades after its introduction into practice, the Judkins catheterization technique remains the
mainstay. Judkins left and right coronary catheters are preshaped to facilitate easy cannulation of
the left and right coronary arteries. Judkins left catheters are labeled based on the length of the distal
portion, ranging from 3 to 6 mm (Figs. 12a and 13). Judkins right catheters are configured from 3.5
to 6.0. JL4 and JR4 catheters are most commonly used for selective left and right coronary
angiography, respectively; longer catheters are useful in more dilated aortic roots.
The Judkins catheterization technique can be used from femoral or radial (or brachial) arterial
access. The Judkins left catheter is shaped to minimize the need for manipulation. The catheter is
advanced into the ascending aorta over a guidewire in the left anterior oblique view. The catheter is
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a s p b c
s s
p p
p
p s
L R L R
Judkins Catheters Amplatz Catheters Multipurpose Catheter
Fig. 12 Common diagnostic coronary catheters. Judkins, Amplatz, and multipurpose catheters are depicted. Left (L)
and right (R) catheters are denoted. The catheter tip is white. The primary (p) and secondary (s) curves are labeled
Table 6 Common catheters for coronary arteries and bypass grafts

Coronary artery or bypass graft Catheter type
Left coronary artery
Normal origin and course JL4
Large ascending aorta JL5, JL6, AL
Small ascending aorta JL3, JL3.5
Anomalous origin from right sinus AR
Anomalous origin of LCx from right sinus JR, AR, Multipurpose
Short left main or separate LCx ostium AL or upsize JL to intubate LCx
Right coronary artery
Normal origin and course JR4
Anterior ectopic origin AR, AL, Hockey Stick
Inferior ectopic origin, inferior course Multipurpose
Superior ectopic origin from ascending Multipurpose
aorta, inferior course
Superior course IM, Williams right
Anomalous from left sinus JL5, JL6, AR2, AR3
Left-sided bypass grafts
Routine JR4
Alternatives Left coronary bypass, AR
Right-sided bypass grafts
Routine JR4
Alternatives Multipurpose, right coronary bypass, AR
LIMA or RIMA
Routine IM
Origin from vertical portion of subclavian JR, Bernstein
Radial arterial access
Routine May use standard catheters as above
Alternatives (single catheter systems) Kimny, Jackie, Tiger, Sarah, Sones, Barbeau, MAC 30/30
JL Judkins left catheter, AR Amplatz right catheter, JR Judkins right catheter, AL Amplatz left catheter, IM internal
mammary catheter
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Fig. 13 Diagnostic coronary catheter shapes and sizes. Multiple different catheters are demonstrated here. Judkins
left and right (JL and JR) and Amplatz left (AL) and right catheters are numbered based on the distance between the
primary and secondary curves (e.g., JL4 has longer distance than JL3.5; AL2 has longer distance than AL1). Left and
right coronary bypass (LCB, RCB) catheters are useful for cannulating aortocoronary bypass grafts. Kimny (Boston
Scientific, Natick, MA), Tiger and Jacky (Terumo, Somerset, NJ), Sones (Cordis, Warren, NJ), and Barbeau are all used
primarily for radial arterial access
then connected to the manifold and de-aired. It is advanced along the aortic wall without manipu-
lation into the left main. If the left main is not immediately intubated, the catheter may be advanced
further to force the tip cephalad. Once engaged, the catheter should be gently pulled back to render it
coaxial. One should avoid injecting when there is too much forward tension required to advance the
catheter, particularly if the catheter is pointed cephalad into the left main “roof.” In this scenario,
exchange the catheter for a larger curve (e.g., upsize from JL4 to JL5). Always check the pressure at
the catheter tip before injecting to avoid dissecting the coronary wall. Slight rotation may be helpful
in cannulating the left main, but excessive rotation should be avoided.
If the catheter folds on itself within the ascending aorta, this suggests that the aortic root is large
and one must upsize the catheter. If the catheter seems trapped in the aortic root and without
sufficient superior orientation, a smaller catheter may be helpful (e.g., downsize from JL4 to
JL3.5) (Fig. 14a).
In patients with short left main or separate ostia, the JL4 catheter may selectively engage the left
anterior descending or left circumflex. Counterclockwise rotation with gentle advancement will
swing the secondary curve posterior and inferior in the aortic root, which turns the primary curve
(tip) anterior and superior toward the LAD. Conversely, clockwise rotation with slight retraction will
swing the secondary curve anterior and superior in the aortic root, which turns the primary curve
posterior and inferior toward the left circumflex. If this is unsuccessful, a shorter secondary curve
(e.g., JL3.5) usually yields a more superior orientation for the LAD, and a longer secondary curve
(e.g., JL5) usually yields a more inferior orientation for the LCx.
Intubation of the right coronary artery requires exchanging for the JR catheter. The catheter is
advanced over a guidewire in the LAO view to the valve plane. The catheter is slowly withdrawn
from the valve plane 2–4 cm while simultaneously rotating the catheter clockwise (anterior)
approximately 180 . Gentle forward and backward movements may help transmit the torque. This
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Fig. 14 Judkins technique. (a) Intubation of the left coronary artery using the Judkins left catheter is demonstrated.
Often, simply advancing the catheter without manipulation will intubate the left main (A1). If the catheter tip lies below
the coronary ostium (A2) despite gentle retraction and torque, a smaller catheter may be necessary (e.g., JL4 to JL3.5). If
the catheter folds on itself (A3), upsizing the catheter may be necessary (e.g., JL4 to JL5). (b) Intubation of the right
coronary artery using the Judkins right catheter is demonstrated using gentle retraction with clockwise rotation
rotation will elongate the catheter tip 1–2 cm caudally and without sufficient retraction may intubate
the left ventricle (Fig. 14b).
Amplatz Technique
Amplatz left (AL) catheters are available at 0.75–4.0 cm (Figs. 12b and 13). These catheters are
particularly useful for high and posterior origins of the left coronary ostium. These catheters may be
used for short left main cannulation of the LAD or LCx and can even be used to cannulate the
RCA. Amplatz right (AR) catheters are 1.0–2.0 cm. These catheters provide more “reach” in larger
aortic roots, high and anterior RCA ostia, or bypass graft cannulation. The catheter is too large if the
catheter tip lies above the coronary ostium or cannot “look up” when in the aortic root. The catheter
is too small if the catheter tip does not reach or points vertically below the ostium. Sometimes
maintaining the guidewire in the catheter with some rotation facilitates shaping the catheter in the
aortic root.
Manipulation of Amplatz catheters requires some experience (Fig. 15). The AL catheter is
advanced over a guidewire into the aortic root. The catheter is advanced until the secondary curve
is supported by the noncoronary cusp, with the catheter tip moving superiorly toward the left main.
Once the catheter tip approximates the left main, slight catheter retraction allows for the catheter tip
to intubate the left main (versus further advancement which paradoxically retracts the catheter
further). This maneuver should be done slowly to prevent deep intubation of the left main with
associated fear of dissection. Cannulation of the right coronary artery with the AL catheter often
requires a similar maneuver, however, with 90–180 clockwise rotation until the catheter points
anteriorly. Gentle retraction of the catheter during rotation may direct the catheter tip more inferiorly
for more successful RCA intubation. The AR catheter requires less manipulation than the AL
catheter for RCA intubation, but has less reach.
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Fig. 15 Amplatz technique. (a) Intubation of the left coronary artery using the Amplatz left catheter often requires
advancing the catheter against the aortic cusp, such that the catheter tip is oriented superiorly toward the left main. Once
engaged, very careful retraction will advance the catheter tip. (b) Intubation of the right coronary artery using the
Amplatz catheters requires gentle retraction and clockwise rotation, followed by advancing the catheter when in the right
coronary cusp, such that the catheter tip moves superiorly into the coronary
Multipurpose Technique
The multipurpose catheter is essentially an endhole catheter that can be used for cannulation of the
right or left coronary artery from femoral or arm access (Figs. 12c and 13). For intubation of the left
coronary ostium, the catheter can be advanced in the LAO projections into the left coronary sinus to
create a small curve. Counterclockwise rotation with simultaneous forward and back motion will
direct the catheter tip superior and posterior toward the left main. For intubation of the RCA, in the
LAO projection, a similar technique as per the Judkins technique can be used. If unsuccessful, create
a small curve in the right coronary cusp and rotate clockwise to swing the catheter tip toward the
RCA ostium.
Aortic Bypass Graft Catheterization

Coronary artery bypass graft (CABG) angiography is essential as percutaneous coronary interven-
tion when feasible may salvage a patient from a redo-sternotomy and bypass. Graft occlusion is
highest in the first year after CABG – 10 % of grafts are occluded at 60 days and 15–25 % at 1 year.
From the 2nd through 5th year, 2 % of grafts occlude per year; from 6th through 10 year, 4 % of
grafts occlude per year. Ten years’ post-CABG, one-third of grafts are occluded, one-third have
significant atheromatous disease, and one-third are patent (Bourassa et al. 1985; Lawrie et al. 1976;
Hwang et al. 1990).
Optimal interrogation of all bypass conduits is facilitated by thorough knowledge of the operative
report. For elective bypass graft angiography, diagnostic coronary angiography should be deferred
until the operative report can be reviewed.
Oftentimes, the Judkins right catheter can be used to selectively engage aortocoronary bypass grafts.
The most caudal bypass graft is commonly the right coronary bypass, then the LAD (if bypassed with
a venous conduit) or diagonal branch, then ramus (if present), and then left circumflex/OM, moving
from inferior to superior (Fig. 16). The right coronary bypass graft is often cannulated using the JR4
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Fig. 16 Aortocoronary bypass grafts. In the left anterior oblique projection, aortocoronary bypass grafts often
originate as shown. The most inferior graft is the usually the graft to the right coronary artery or posterior descending
coronary artery. The most superior graft is often to the left circumflex or obtuse marginal system
catheter, just above the native right coronary artery ostium in the LAO projection. This can often be
cannulated by retracting the JR4 catheter from the native RCA. When the right coronary bypass is
inferiorly oriented, a multipurpose catheter may better intubate the right coronary ostium.
In the same LAO projection, moving the Judkins right catheter along the anterior wall (pointing
slightly leftward) and retracting the catheter, the remainder of the grafts can often be localized. If not,
exploring the aortic wall with 5–10 rotation and forward and backward movements may help identify
the graft ostium. If the aorta is large or the grafts are superiorly directed, left coronary bypass catheter,
left mammary catheter, or Amplatz left catheters may engage the grafts more selectively.
All grafts should be interrogated. A bypass graft should not be assumed to be occluded until
a stump is demonstrated. Nonselective aortography with a Pigtail catheter in the RAO projection
with 40 cc contrast at 20 cc/s may be helpful in trying to find additional bypass grafts. Indirect
evidence of a patent graft may be derived from retrograde flow into the graft or “competitive” (to and
fro) during injection of native coronaries (Levin et al. 1971).
Internal Mammary Catheterization

The right and left internal mammary arteries originate from the right and left subclavian arteries,
respectively. These arteries are preferred coronary bypass conduits; in contrast to aortocoronary
venous bypass grafts, 95 % of left internal mammary grafts are patent at 1 year, and 85–95 % are
patent at 10 years (Cameron et al. 1996). The majority of CABG surgeries performed today use at
least one internal mammary artery. The prevalence of subclavian stenosis in patients undergoing
diagnostic coronary angiography has been estimated around 3.5 % and at least 5.3 % in patients with
potential surgical coronary disease (English et al. 2001). The specificity of clinically relevant
subclavian artery stenosis (>50 %) is high if there is a difference in brachial blood pressures of
>20 mmHg (English et al. 2001).
Interrogation of the internal mammary arteries involves selective interrogation of the respective
subclavian artery. For interrogation of the left subclavian artery, the Judkins right catheter is most
commonly used. The catheter is rotated counterclockwise such that the catheter tip points cranially.
The catheter is withdrawn and usually cannulates the innominate, the left carotid, then the left
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RAO
LAO RAO
b
RAO 20, Caudal 20
RAO
LAO
RAO LAO
Fig. 17 Subclavian, innominate angiography, and internal mammary angiography. (a) The subclavian artery and
origin of the internal mammary artery is often best imaged in the contralateral anterior oblique view; the left subclavian
artery and left internal mammary artery origin are shown here in the right anterior oblique (RAO) view. (b) The
innominate and right subclavian origins are best imaged in the RAO 20 with caudal 20 . The right subclavian artery and
right internal mammary artery to the right coronary artery are shown. As shown here in panels (a) and (b), the
anastamosis between the internal mammary artery and native coronary artery should be imaged in two views (usually
LAO and RAO, red arrow)
subclavian; the catheter is then advanced very slightly and gently once the tip has cannulated the left
subclavian (Fig. 17). A moderate subclavian stenosis can be further interrogated by a pullback
gradient or simultaneous invasive central aortic pressure and noninvasive left brachial blood
pressure. A difference of 20 mmHg is considered significant.
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In order to cannulate the left internal mammary artery, a guidewire (exchange length if one needs
to exchange catheters) is advanced into the distal left subclavian or proximal left axillary artery. In
cases of tortuosity, a hydrophilic glide wire may facilitate navigating the vessel. Over the guidewire,
a JR4 or internal mammary (IM) catheter can be advanced past the takeoff of the internal mammary
artery (IMA). A JR4 catheter is often most conducive when the origin of the IMA arises from the
vertical portion of the subclavian. An IM catheter may be better when the origin is more vertical,
particularly from the more horizontal segment of the subclavian. The catheter is then connected to
the manifold and retracted with the tip directed inferiorly with small test injections to locate the
ostium of the left internal mammary artery. 5–10 of counterclockwise rotation may be beneficial to
engage the ostium. Arterial pressure should be assessed before injecting into the left internal
mammary artery to avoid dissection.
In order to cannulate the right internal mammary artery, the right subclavian artery must be
cannulated. The right innominate artery is cannulated in a similar fashion as the left
subclavian – a Judkins right catheter is advanced past the ostium of the innominate, rotated
counterclockwise, and retracted until the innominate is cannulated. In the RAO 20 and caudal 20
angulation, the right subclavian and common carotid bifurcation is well displayed, and a guidewire
can be advanced into the right subclavian for the purposes of angiography. Similar to the left internal
mammary artery, a guidewire is advanced into the distal right subclavian or proximal right axillary
artery, and the catheter is advanced. A JR4 or IM catheter can be used for selective right internal
mammary angiography; gentle retraction and clockwise rotation usually facilitates intubation.
Again, test injections may help, and arterial pressure should be assessed before injecting into the
right internal mammary artery to avoid dissections.
Imaging the IMA in the AP and lateral projections can often help Cardiac Surgeons plan re-do
sternotomy by seeing if the IMA crosses the midline sternum (AP) and if there is any adhesions of
the artery to the sternum (lateral).
Gastroepiploic Artery Catheterization

The gastroepiploic artery is rarely used for arterial coronary revascularization. This artery is the
largest terminal branch of the gastroduodenal artery, which commonly arises from the common
hepatic artery and supplies the stomach. As a bypass conduit, it is tunneled through the diaphragm
and anastomosed to the posterior descending branch of the RCA.
Cannulating the celiac artery can be done from femoral or arm arterial access. From femoral
arterial access, many possible catheters (e.g., Cobra, Omniflush, SOS, Judkins right, IM) can be used
to cannulate the celiac artery, often in the lateral projection. A hydrophilic wire is then navigated into
the vessel, over which a 4 F IM or JR4 catheter can track for selective angiography. Figure 18
demonstrates gastroepiploic angiogram.
Angiographic Projections
Selective coronary angiography enables direct visualization of the epicardial coronary arteries and
their first-, second-, and third-order side branches to a diameter of 100–200 mm. Smaller branches
and the capillary network may not be visualized, but carry less significance.
Epicardial coronary arteries largely follow the atrioventricular and interventricular groove,
corresponding to the long and short axis of the heart. The X-ray beam is aligned perpendicular to
the vessel for complete delineation of the artery. The X-ray is positioned in the right and left anterior
oblique (RAO and LAO, respectively), to account for the oblique orientation in the thorax.
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Native RCA
Right Gastroepiploic Artery

R&L
Hepatic Celiac Aorta
Arteries Artery
Gastroduodenal Hepatic Artery

Artery
Splenic
Pancreatico- Artery
Duodenal
Artery
Fig. 18 Gastroepiploic artery bypass graft. While not commonly used, the gastroepiploic artery is another arterial
conduit that has been used to bypass the native right coronary artery. It originates from the gastroduodenal artery, which
arises from the hepatic artery, which arises from the celiac artery. It can often be imaged in the RAO and LAO projections
and even AP (Adapted from Hillegass et al. (2003) J Invasive Cardiol 15(1))
Cineangiographic equipment consists of a C-arm mount X-ray tube under the patient and an
image intensifier above. The C-arm and image intensifier rotate in parallel 45 in the longitudinal
(cranial/caudal) or 180 in the horizontal (RAO/LAO) plane. By convention, the position of
the image intensifier relative to the patient determines the nomenclature of the angiographic
projection.
Coronary angiography should image each vessel segment in at least two orthogonal views.
Figure 19 provides a schematic of the standard angiographic views. As a general rule, for the left
coronary artery, caudal angulations delineate the LCx and the cranial views are more effective
for visualizing the LAD. Each of the most common angiographic views is labeled in Figs. 20–31.
Right Anterior Oblique

Right anterior oblique (RAO) refers to the image intensifier to the right of the patient as if the
observer were looking at the heart from the right side. Angiographically, RAO is recognized by the
spine to the left of the image. For the left coronary artery, RAO with 20–30 caudal angulation
interrogates the left main, proximal and body of the left circumflex and obtuse marginal systems
(Fig. 20). RAO with 20–30 of cranial angulation interrogates the mid-distal LAD, septal branches,
and terminal LCx, and obtuse marginal branches (Fig. 21). For the right coronary artery, straight
RAO (30 ) visualizes the mid-RCA, as well as the conus branch, the posterior descending, and right-
to-left collaterals (Fig. 22).
Left Anterior Oblique

Left anterior oblique (LAO) refers to the image intensifier to the left of the patient. Angiograph-
ically, the spine is located to the right of the image. For the left coronary, 40–60 LAO with 10–30
of caudal images the left main and ostial/proximal LAD and LCx (Fig. 23). This view is termed the
“spider view.” LAO 30–45 with 20–30 of cranial angulation images the mid-LAD and the
diagonal branches (Fig. 24). It is ideal to adjust the image intensifier to place the catheter tip between
the shadow of the diaphragm and the spine; patient inspiration can help increase the radiolucent area
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over which the LAD will course. This projection will also image a left dominant posterior
descending coronary artery. For the right coronary, straight LAO (30 ) delineates the ostium,
mid-, and distal RCA (Fig. 25). In right dominant coronary circulation, the distal RCA, posterolat-
eral, and posterior descending coronary arteries are separated in the LAO with 20–30 of cranial
angulation (Fig. 26).
b
RAO AP LAO
A C E
Cranial
RAO 20, Cran 20 AP, Cran 30 LAO 30, Cran 30
B D F
Caudal
RAO 20, Caud 20 AP, Caud 30 LAO 30, Caud 30
Fig. 19 (continued)
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d
AP 30
RAO 30 LAO 30
Fig. 19 Angiographic views. (a) Schematic of standard angiographic projections for imaging the left coronary artery.
(b) Representative angiographic images of left coronary artery. The above angiograms demonstrate the most common
left coronary angiographic views. Cranial angulations better delineate the LAD (black arrow); caudal angulations better
delineate the LCx (white arrow). (c) Schematic of standard angiographic projections for imaging the right coronary
artery. (d) Representative angiographic images of right coronary artery angiographic views. The right coronary artery
(black arrow), conus branch (dashed yellow arrow), sinoatrial branch (solid yellow arrow), right ventricular acute
marginal (white arrow), posterior descending artery (red arrow), and posterolateral branches (blue arrows) are depicted
in the above standard angiographic views. (RAO right anterior oblique, LAD left anterior oblique, LCX left circumflex,
LAO left anterior oblique, D diagonal, S septal, LM left main, PLA posterolateral artery, PDA posterior descending artery,
RV-M right ventricular marginal, AV atrioventricular nodal artery)
Fig. 20 RAO 20/caudal 20. Trifurcation of the left main coronary artery (big blue arrow) into the left anterior
descending (red arrow), ramus intermedius (white arrow), and left circumflex (yellow arrow; obtuse marginal
branches – dashed yellow arrows) coronary arteries
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Fig. 21 RAO 20/cranial 20. This view elucidates the mid- and distal LAD and occasionally diagonal branches. The
distal LCX may be occasionally visualized in this view. LAD (red arrow), diagonal branches (dashed red arrow), septal
perforators (orange arrow), LCX (yellow arrow), left main (large blue arrow)
Fig. 22 RAO 30/cranial 0. This view shows the mid-right coronary artery, as well as posterior descending coronary
artery (red), right ventricular (acute) marginal branches (white), and atrial branches (dashed yellow arrow)
Anteroposterior and Lateral Projections

The anteroposterior (AP) projection can identify the origin of the left main from the aorta (Fig. 27).
Caudal angulation of 20–30 can further delineate the mid-distal left main and origin of the LAD and
LCx (Fig. 28). Cranial angulation of 30–45 can often follow the entire course of the LAD, though
the ostium can be overlapped (Fig. 29).
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Fig. 23 LAO 30/caudal 20. “spider view” Trifurcation of the left main coronary artery (big blue arrow) into the left
anterior descending (red arrow; diagonal branch – dashed red arrow), ramus intermedius (white arrow), and left
circumflex (yellow arrow; obtuse marginal branches – dashed yellow arrows) coronary arteries
Fig. 24 LAO 30/cranial 20. This view best demonstrates the proximal diagonal branches as they originate from the
LAD. The left main ostium can often be seen. The mid-LCX can be well seen in this view occasionally. LAD (red
arrow), diagonal branches (dashed red arrow), septal perforators (orange arrow), LCX (yellow arrow), left main (large
blue arrow)
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Fig. 25 LAO 30/cranial 0. (a) This view elucidates the ostium, mid-, and distal right coronary artery (black arrow),
sinus nodal artery (yellow), conus branch (yellow dashed), right ventricular (acute) marginal branches (white), posterior
descending coronary artery (red), and posterolateral branches (blue). (b) The conus branch may have a separate ostium
Fig. 26 LAO 10/cranial 20. This view shows the distal right coronary artery (black arrow) and its bifurcation into rise
to posterior descending coronary artery (red) and posterolateral branches (blue). The right ventricular (acute) marginal
branch (white) is identified
The lateral projection can provide further detail of the mid-distal LAD and the vertical (mid)
portion of the RCA (Fig. 30).
Table 7 identifies more specific angiographic angles for specific vessels.
Bypass Graft Angiography

Similar to native coronary angiography, the ostium, body, and distal anastomosis should be
interrogated during bypass graft angiography. Two orthogonal views of each segment should be
obtained. Oftentimes, LAO and RAO projections can provide sufficient information in addition,
a view that demonstrates the anastomosis (as per table above). For RCA (or PDA) bypass grafts,
LAO, RAO, lateral, and LAO cranial projections will provide a complete interrogation. For LIMA-
LAD bypass grafts, RAO, LAO, RAO cranial, LAO cranial, and lateral projections may be useful.
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Fig. 27 AP. Left coronary artery. The proximal and mid-left main coronary artery (blue arrow) can often be evaluated in
this view. Otherwise, there is significant overlap in the distal left main, as well as the left anterior descending coronary
artery and left circumflex
Fig. 28 AP/caudal 20. The left circumflex and obtuse marginal branches are well seen in this view. The left main, ostial,
and proximal LAD can be well visualized in this view. A left atrial branch is seen (green arrow). LAD (red arrow),
diagonal branches (dashed red arrow), septal perforator (orange arrow), LCX (yellow arrow), obtuse marginal branches
(dashed yellow arrows), left main (large blue arrow)
For LCx and ramus intermedius bypass grafts, RAO and LAO with caudal angulation can be helpful
(Fig. 31).
Imaging the IMA in the AP and lateral projections can often help Cardiac Surgeons plan re-do
sternotomy by seeing if the IMA crosses the midline sternum (AP) and if there is any adhesions of
the artery to the sternum (lateral).
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Fig. 29 AP/cranial 30 This view elucidates the mid- and distal LAD and occasionally diagonal branches. The left
circumflex is not well visualized in this view. LAD (red arrow), diagonal branches (dashed red arrow), septal perforators
(orange arrow), LCX (yellow arrow), left main (large blue arrow)
Fig. 30 Lateral (a) Left coronary artery. This view demonstrates the proximal mid- and distal left coronary artery. LAD
(red arrow), LCX (yellow arrow), obtuse marginal branches (dashed yellow arrows). (b) Right coronary artery. This
view demonstrates the mid-right coronary artery (black) and right ventricular (acute) marginal branch (white)
The left subclavian can be imaged in the LAO and RAO projections (Fig. 17a). The RAO
projection best demonstrates the origin of the left IMA, while the LAO demonstrates the right
IMA origin.
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Table 7 Angiographic angles for specific vessels

Vessel segment of interest Angiographic projection
Left main AP
AP, 10–30 caudal
40–60 LAD, 10–20 caudal
30–45 LAO, 20–30 cranial
Proximal LAD 20–30 RAO, 20–30 caudal
AP, 30–40 cranial
Mid LAD 10–30 RAO, 20–30 cranial
AP, 30–40 cranial
Lateral
Distal LAD 10–30 RAO, 20–30 cranial
20–30 RAO, 20–30 caudal
AP, 30–40 cranial
Lateral
Diagonal branches 30–45 LAO, 20–30 cranial
10–30 RAO, 20–30 cranial
Proximal LCx 20–30 RAO, 20–30 caudal
40–60 LAO, 10–20 caudal
Ramus intermedius 20–30 RAO, 20–30 caudal
40–60 LAO, 10–20 caudal
Obtuse marginal branches 20–30 RAO, 20–30 caudal
40–60 LAO, 10–20 caudal
10–30 RAO, 20–30 cranial
Proximal RCA 60 LAO
Mid-RCA 60 LAO
30 RAO
Lateral
Distal RCA Lateral
PDA 30–45 LAO, 20–30 cranial
30 RAO
Posterolateral branches 30–45 LAO, 20–30 cranial
Coronary Angiographic Interpretation

Commonly, the severity of coronary artery stenosis is determined by qualitative visual estimation.
The diameter of the diseased segment is expressed as a percentage of the normal reference segment.
Earlier animal studies suggest that a decrease in luminal diameter of 50 %, corresponding with
decrease in cross-sectional area of 75 %, corresponds with reduction in normal three to fourfold
increase in coronary flow reserve during exercise-induced hyperemia (Gould et al. 1974). Serial
stenoses and longer lesions have additive effects on reducing coronary flow reserve (Feldman
et al. 1978).
A high-quality coronary angiogram is necessary to assess coronary stenoses. While slow contrast
injections may fail to opacify the vessel adequately, forceful injections may displace the catheter
from the ostium or result in coronary dissections. Injection of 3–10 mL of contrast is often sufficient
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LAO RAO
LAD
Diagonal
OM
RCA
Fig. 31 Aortocoronary bypass graft angiograms. The most common aortocoronary bypass grafts are conduits (either
arterial – IMA pedicle or radial – or saphenous veins) to the left anterior descending, diagonal, obtuse marginal, or right
coronary arteries. These are commonly interrogated in the left and right anterior oblique (LAO, RAO, respectively)
projections with additional projections as needed, oftentimes similar to projections as previously demonstrated for
specific portions of the native vessel. Here are representative images from the LAO and RAO projections for the most
common aortocoronary bypasses
to rapidly fill the artery, delineate the luminal borders, and assess runoff. The rate of injection may
differ based on size and resistance of the artery. Careful attention to transduced pressures will help
avoid complications (Fig. 32).
Qualitative angiography should assess:
1. Lesion location. While often used for research purposes, the Coronary Artery Surgical Study
schematic provided a framework for identifying the various vessel segments. Since the advent of
the SYNTAX score, these segments are now commonly used as a framework to describe lesion
location (Fig. 3).
2. Lesion severity. This is often characterized by percent diameter stenosis, calculated as
% stenosis ¼ ðminimal lumen diameter at stenosis site=reference diameterÞ 100
The minimal luminal diameter will be captured when the vessel is imaged in profile, though the
minimal luminal diameter seen in all views is often used clinically. Figure 33 demonstrates the
relationship between % diameter stenosis and decrease in cross-sectional area (Arnette and
Roberts 1976).
3. Lesion length. This is characterized from “normal to normal” using the distal normal reference
diameter and proximal normal reference diameter.
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a 50 mm/s b 50 mm/s
150 150
100 100
50 50
0 0
Fig. 32 Abnormal catheter pressure. When the catheter tip is obstructed by an ostial stenosis or unfavorable position
up against the vessel wall, there can be either (a) “ventricularization” of the pressure waveform, mimicking a ventricular
pressure, with a normal systolic (black arrow) and significantly decreased diastolic (red arrow) pressure or (b)
“damping” of pressure waveform with decreased systolic and diastolic pressures. The catheter tip should be manipulated
until the waveform normalizes, prior to deciphering the cause. Contrast should not be injected while the pressure
transduced from the catheter tip is ventricularized or dampened
4. Vessel diameter distal to the lesion. The stent diameter is often selected relative to the distal
reference diameter, as oversizing to the distal diameter may lead to dissection.
5. Lesion morphology. Lesion-specific characteristics of coronary stenoses have been classified as
types A, B, and C lesions by the American College of Cardiology/American Heart Association
(Table 8) and type I–type IV (Society for Cardiovascular Angiography and Interventions
(SCAI)). These classification schemes have been associated with procedural success and com-
plication rates in patients undergoing percutaneous coronary intervention (Ryan et al. 1993; Ellis
et al. 1990).
6. Coronary artery perfusion. Semiquantitative assessment of coronary perfusion includes the
Thrombolysis in Myocardial Infarction (TIMI) classification (Sheehan et al. 1987), which is
the most widely used assessment and is described in Table 9. Other less common assessments
include TIMI frame count (cineangiographic frames for complete opacification of the artery), or
TIMI blush score for myocardial perfusion.
7. Description of collateral circulation. This will be covered later in the chapter.
However, there is considerable intra- and interobserver variability in visual estimation of coronary
angiography.
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Fig. 33 Coronary stenosis relationships. Relationship between orthogonal angiographic decrease in diameter and
corresponding histologic decrease in cross-sectional area is demonstrated
Table 8 ACC/AHA lesion morphology

Type A lesion Short (<10 mm)
Concentric
Smooth contour
Nonangulated (<45 )
No calcification
Nonostial location
No side branch involvement
No thrombus
Type B lesion Tubular (10–20 mm length)
Eccentric
Moderately angulated (45–90 )
Irregular contour
Moderate calcification
Total occlusions <3 months old
Ostial location
Bifurcation lesion
Thrombus present
Type C lesion Diffuse (length >20 mm)
Extremely angulated (>90 )
Total occlusion >3 months old
Inability to protect major side branch
Degenerated vein grafts with friable lesions
More recent studies suggest that visual estimation may not be sufficient in determining prognostic
importance of a lesion. The FAME study suggested that patients treated for angiographic stenosis
based on visual estimation (>50 % in at least 2 major epicardial vessels and PCI was felt indicated)
had a higher rate of composite death, nonfatal myocardial infarction, and repeat revascularization, as
compared with patients treated based upon lesions assessed physiologically with fractional flow
reserve (<0.80) (Tonino et al. 2009).
Additional tools for deciphering coronary artery stenosis – for example, fractional flow reserve,
intravascular ultrasound, and optical coherence tomography – are covered in separate chapters.
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Table 9 TIMI assessment of perfusion

Grade 0 No perfusion. No perfusion of contrast material beyond stenosis
Grade 1 Minimal perfusion. Contrast material flows through the stenosis but fails to opacify the distal vasculature
Grade 2 Partial perfusion. Contrast material flows through the stenosis but fills the distal vasculature at a slower rate
than a normal vessel
Grade 3 Normal perfusion. Contrast material fills the vasculature distal to the stenosis as rapidly and completely as
in a normal vessel
Table 10 TIMI myocardial perfusion grade

Grade 0 Contrast fails to enter the microvasculature. There is either minimal or no ground glass appearance (“blush”)
or opacification of the myocardium in the distribution of the culprit artery indicating lack of tissue-level
perfusion
Grade 1 Contrast slowly enters but fails to exit the microvasculature. There is the ground glass appearance
(“blush”) or opacification 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 s between injections)
Grade 2 Delayed entry and exit of contrast from the microvasculature. There is the ground glass appearance (“blush”)
or opacification of the myocardium in the distribution of the culprit lesion that is strongly persistent at the end
of the washout phase (i.e., dye is strongly persistent after three 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 contrast from the microvasculature. There is the ground glass appearance (“blush”)
or opacification of the myocardium in the distribution of the culprit lesion 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 three cardiac cycles of the washout phase and noticeably diminishes in intensity
during the washout phase) similar to that in an uninvolved artery. Blush that is of only mild intensity
throughout the washout phase but fades minimally is also classified as grade 3
Corrected TIMI Frame Count (CTFC)

CTFC is another tool for semiquantitative assessment of coronary flow. TIMI frame count is the
number of cineangiographic frames from initial contrast opacification of the proximal coronary
artery to opacification of distal arterial landmark. This is then corrected for the length of left anterior
descending coronary artery. Lower CTFC in an infarct-related vessel following reperfusion with
thrombolytic or primary angioplasty is associated with greater functional recovery.
TIMI Myocardial Perfusion Grade (TMPG)

Both TIMI flow and CTFC are reflective of epicardial coronary flow. However, these may not reflect
myocardial perfusion due to microvascular obstruction. TIMI myocardial perfusion grade is
a simple semiquantitative method that has been shown to have additional prognostic value in
patients undergoing reperfusion therapy for acute myocardial infarction (Table 10) (Gibson et al.
1996; Hamada et al. 2001; Stone et al. 2002).
SYNTAX Score
The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score is a lesion-based
angiographic scoring system that was introduced as a tool for grading the complexity of coronary
artery disease prior to randomizing patients to coronary artery bypass grafting or percutaneous
coronary intervention (Yadav et al. 2013). The score can be calculated using www.syntaxscore.com.
The SYNTAX trial noted that patients in the highest tertile of SYNTAX score (>32) benefit from
surgical revascularization, whereas PCI carries equivalent risk for major adverse cardiac or
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Table 11 Nomogram describing the global risk classification
EuroScore SYNTAX score

10–22 23–32 >32
0–2 Low Low Intermediate
3–6 Low Low-intermediate Intermediate-high
>6 Intermediate Intermediate High
Adapted with permission from (Yadav et al. 2013)
cerebrovascular events at 3 years among the lower two tertiles [10-22, 23-32]. This landmark trial
has furthered collaborative, multidisciplinary decision-making by cardiologists and cardiac sur-
geons based on diagnostic coronary angiograms. Despite its prognostic value and guideline-
recommended, collaborative spirit, the reliance on angiographic variables alone without functional
or clinical data renders the SYNTAX score imperfect. However, the SYNTAX score has become an
accepted way to evaluate multivessel coronary disease based on diagnostic angiograms and the basis
for other derived risk scores. Table 11 uses risk classifications to group patients into low, interme-
diate, or high risk for percutaneous coronary intervention.
Quantitative Coronary Angiographic Interpretation

Quantitative coronary angiography (QCA) is rarely used, except in research protocols, where
more objective and reproducible assessments are required (Ng and Lansky 2011). QCA uses
computer-assisted algorithms to analyze digitized images of coronary angiograms. QCA provides
quantifiable and reproducible minimal and reference diameters, % diameter and area stenosis, area
of atherosclerotic plaque, stenosis geometry, stenosis length, and eccentricity index. To perform
QCA, one must select a region of interest, with (1) complete opacification of the vessel with contrast,
(2) absence of lesion foreshortening and overlap, and (3) frame capture in end diastole. Calibration
of the QCA system enables accurate measurements of size and length. The system can be calibrated
using (1) measurement of an object with known dimensions (e.g., catheter shaft, or distance between
markers, etc.), or much less frequently, and (2) geometric analysis by positioning the region of
interest in the isocenter and determining the distance between image intensifier and patient. While
using the catheter shaft for calibration, the (1) catheter should be flushed with normal saline to avoid
contrast variability observed in contrast-filled catheters, (2) accuracy should be realized to be
proportional to catheter size (>5–6 F), and (3) the catheter used for calibration should be measured
with a micrometer to confirm its actual size as it may deviate from manufacturer’s dimensions.
The problem of pincushion distortion – selective magnification of an object near the edges
compared with the center – is often described, but is irrelevant with modern image intensifiers.
Following calibration, smoothing, and pincushion correction, arterial contours are defined by
applying an edge detection algorithm. Automatic edge detector algorithms have been developed
to define luminal borders. These algorithms use densitometric planes perpendicular to the longitu-
dinal axis of the vessel, which are analyzed in an iterative fashion by numeric derivatives and
a minimal-cost contour approach, which are beyond the scope of this chapter. In addition to
quantitative measures, some functional information can be theoretically derived as well, such as
coronary flow reserve and transstenotic pressure gradients.
Pitfalls of Coronary Angiography

The role of coronary angiography is to define the entire coronary arterial tree. Angiographic
projections must be individualized to accommodate variations in anatomy, define bifurcations,
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and avoid superimposition of vessels. There are particular situations in which defining the coronary
arterial tree with coronary angiography can prove difficult:
1. Left main disease/bifurcation. Left main stenosis is prognostically important. Ostial left main
stenosis can be corroborated by clinical suspicion, or indirect clues such as pressure dampening or
ventricularization on catheter engagement or lack of contrast reflux during injection (Fig. 32). For
ostial disease, downsizing the catheter from 5–6 F to 4–5 F may be helpful. For distal bifurcation
disease, optimal vessel opacification may be enhanced by upsizing the catheter or using a guide
catheter. The distal left main and proximal left circumflex, in particular, can be difficult to
delineate. Straight AP projections may be helpful with slight caudal or cranial angulation. If
severe left main stenosis is demonstrated, angiographic images should be minimized to limit
ischemic time imposed by catheter obstruction and contrast exposure. If suspected, but difficult to
demonstrate, adjunctive assessments, such as intravascular ultrasound, fractional flow reserve, or
optical coherence tomography, should be considered, given the importance of this diagnosis.
2. Right coronary/posterior descending coronary bifurcation stenosis. The origin of this bifurcation
can be challenging to define. Cranial views with AP or LAO angulation can often be helpful to
separate the ostial PDA from the posterolateral branch and the overlapping catheter (if femoral
access).
3. Eccentric stenosis. Coronary stenoses are more often eccentric and can be “hidden” in certain
angiographic views. For this reason, complete imaging of coronaries in two orthogonal views is
important. Orienting the X-ray beam parallel to the vessel/stenosis will manifest the severity of
the stenosis. Adjunctive imaging may help.
4. Total occlusions. Total occlusions often occur at bifurcations and may go undetected. Operators
must pay close attention that all myocardial territories are perfused by a coronary artery.
Prolonged angiograms and awaiting the venous phase may demonstrate collateral flow. Total
occlusions may recanalize in 1/3 of cases. However, distinguishing between recanalized total
occlusions versus bridging collaterals may be difficult. If multiple angiographic views, including
lateral projections, cannot be distinguished, the behavior of the wire during attempted interven-
tion may provide additional clues.
5. Vessel tortuosity, overlap, and foreshortening. Representing 3-dimensional structures in two
dimensions has inherent issues. Orthogonal images are important, but adjunctive imaging may
be important.
Coronary Collateral Circulation

Epicardial coronary arteries are interconnected by many precapillary arterial vessels. These vessels
are 20–200 mm. Under physiologic conditions, these vessels are not visible angiographically. In the
case of significant stenosis, these collateral vessels are recruited and enlarge to supply an
underperfused territory, thereby reducing myocardial ischemic burden (Williams et al. 1976).
These collateral vessels may be intracoronary (“bridging”) between adjacent segments of the
same vessel or intercoronary, between two different – ipsi, or contralateral – coronary arteries.
Development of coronary circulation occurs in several phases. During the first phase, physical
pressure and flow result in passive opening and dilation. During the second proliferative phase,
growth factors result in angiogenesis and growth of collateral vessels. During the final remodeling
phase, expression of smooth muscle and extracellular matrix transforms the structure of the
collateral into a normal three-layer arterial structure (Gregg and Patterson 1980).
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Similar to the TIMI classification of native coronary perfusion, Cohen and Rentrop introduced
a semiquantitative method for assessing coronary collateral blood flow (Table 12; Yadav et al. 2013).
Levin comprehensively described the most common collateral pathways. Figure 34a–c describes
these collateral pathways (Levin 1974).
Fig. 34 (continued)
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Fig. 34 Coronary artery collateral pathways. (a) Collateral pathways to an occluded right coronary artery (RCA)
from the 1 – left anterior descending (LAD) via septal branches to the posterior descending coronary artery (PDA),
2 – distal left circumflex coronary artery (LCx) to distal RCA, 3 – obtuse marginal (OM) branch to posterolateral
branch (PLA), 4 – right ventricular marginal (RVM) branch to ipsilateral distal RCA, 5 – Kugel’s artery of proximal RCA
or LCx to atrioventricular (AV) nodal artery to distal RCA, 6 – distal LAD via apex to distal PDA, 7 – distal LCx via AV
nodal artery to distal RCA, 8 – low RVM to PDA, 9 – sinus nodal artery to PLA, 10 – RVM of LAD to RVM of RCA.
(b) Collateral pathways to an occluded LAD from the 1 – RVM to LAD, 2 – proximal septal branches to distal LAD,
3 – diagonal branch to distal LAD, 4 – OM branch to the LAD, 5 – conus branch to proximal LAD (Vieussens’
collateral), 6 – PDA via septal branches to distal LAD, 7 – PDA via apex to distal LAD. (c) Collateral pathways to an
occluded LCx from the 1 – left atrial branch of the LCx to the distal LCx, 2 – proximal OM to a distal OM, 3 – diagonal
branch to OM branch, 4 – distal RCA to distal LCx, 5 – PLA to OM
Coronary Anomalies
There are variations in coronary anatomy. Some of these anomalies may not have a significant
impact on a patient’s clinical course; where other anomalies may be clinically significant. Levin
characterized coronary anomalies as those with hemodynamic (or ischemic) consequence and
those without (Levin et al. 1978). This classification is still used.
Coronary Artery Anomalies with Hemodynamic Significance

Large Coronary Artery Fistulae
Coronary artery fistulae are precapillary communications between an epicardial coronary artery
and a cardiac chamber or other major vascular structures. Coronary fistulae draining into venous
structures are arteriovenous fistulae, whereas fistulae emptying into cardiac chambers are coronary-
cameral fistulae. They are observed in 1–2 % of coronary angiograms (Levin et al. 1978). More than
half are asymptomatic. Small fistulae are often asymptomatic and require no specific attention. They
can be acquired from deceleration injuries, coronary angioplasty, pacemaker leads, or repeat
myocardial biopsies. The most common small fistula in adults is a communication between the
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Table 12 Assessment of coronary collateral perfusion

Grade 0 No collateral blood flow
Grade 1 Minimal collateral blood flow. Blood flow through collateral vessels, but is insufficient to opacify the
vessel distal to the occlusion
Grade 2 Partial collateral blood flow. Blood flows through collateral vessels and partially but not fully fills the
vessel distal to the obstruction
Grade 3 Complete collateral blood flow. The vessel distal to the occlusion is briskly and fully opacified
Fig. 35 Large coronary artery fistula. Coronary injection of a large coronary-cameral fistula originating from the left
main (Amplatz left catheter noted with solid white arrow) and draining into the right atrium (dashed arrow) close to the
coronary sinus in the (a) AP and (b) LAO caudal projections. This fistula accounted for dyspnea and continuous systolic-
diastolic murmur (Reproduced with permission from Dr. Windecker, Panvascular Medicine, 1st edn, Lanzer
P (ed) chapter 47, Springer 2002)
LAD and main pulmonary artery. Small coronary artery fistulae are not associated with continuous
murmurs.
On the other hand, the clinical presentation of a patient with a large coronary artery fistula depends
on the type of fistula, shunt volume, site of the shunt, and presence of other cardiac conditions
(Fig. 35). Symptoms develop due to heart failure from left-to-right shunting, myocardial ischemia
from steal phenomena, infective endocarditis, or rupture of an aneurysmal fistula (Sapin et al. 1990).
Coronary fistulae originate from RCA in 50 %, left coronary in 40 %, or multiple vessels.
Treatment of coronary fistulae is often warranted in patients with heart failure and a shunt volume
of >1.5:1. In addition to angiography, CT angiography can be helpful in evaluating these lesions.
Percutaneous intervention has become a more accepted strategy to treat symptomatic lesions, with
the goal of maintaining antegrade coronary flow while obliterating the fistula (Perry et al. 1992),
(Fig. 36).
Ectopic Origin of Coronary Arteries from the Pulmonary Trunk

This is the second most common coronary anomaly with hemodynamic significance. The more
common and concerning anomaly is origin of the left coronary artery from the pulmonary artery,
termed ALCAPA or Bland-White-Garland syndrome (Bland et al. 1933; Fig. 37). It frequently
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Pulmonary Artery
LM
JR 4
RCA
LAD
Fig. 36 Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Also known as
Bland-Garland-White syndrome. Right coronary angiography via Judkins right 4 (JR4) diagnostic catheter opacifies the
right coronary artery (RCA), as well as the left anterior descending (LAD) and left main via collaterals with retrograde
filling of its origin from the pulmonary artery, demonstrating left-to-right shunting associated with this lesion
(Reproduced with permission from Dr. Windecker, Panvascular Medicine, 1st edn, Lanzer P (ed) chapter 47, Springer
2002)
Fig. 37 Five crossing pathways of anomalous coronary arteries. (1) Retrocardiac, (2) retroaortic, (3) preaortic,
(4) intraseptal, or (5) prepulmonic. The retroaortic course is the most common pathway, particularly with the left
circumflex originating from the right sinus of Valsalva. The intraseptal pathway is intramural and identifiable by its
phasic systolic compression. The prepulmonic pathway is most common in patients with tetralogy of Fallot
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results in severe heart failure and during infancy due to left coronary perfusion by insufficient
venous pressure and low oxygen tension. In the 20 % of patients that survive to adulthood, the right
coronary artery provides sufficient collaterals (Wesselhoeft et al. 1968). However, those who survive
may develop early angina, heart failure, or mitral regurgitation; and sudden cardiac death remains
a complication in adults. Surgical correction with reimplantation is often required.
Congenital Stenosis or Atresia of the Coronary Arteries

Coronary atresia is rare and is rarely observed in isolation. It has been associated with other
congenital diseases, such as Hurler’s syndrome, homocystinuria, congenital rubella syndrome,
supravalvular aortic stenosis, and Friedreich’s ataxia (Levin et al. 1978). Survival into adulthood
depends on sufficient collateralization. Surgical correction has been described (Musiani et al. 1997).
Ectopic Origin of Both Coronary Arteries from the Same Sinus

Contralateral sinus ectopic origin requires careful topographical determination of the anomalous
course with respect to the great vessels. The origin, crossing pathway to the contralateral side, and
distal perfusion territory are important. Figure 37 describes the five crossing pathways:
(1) retrocardiac, (2) retroaortic, (3) preaortic, (4) intraseptal, or (5) prepulmonic. The retroaortic
course is the most common pathway, particularly with the left circumflex originating from the right
sinus of Valsalva. The intraseptal pathway is intramural and identifiable by its phasic systolic
compression. The prepulmonic pathway is most common in patients with tetralogy of Fallot
(Levin 1974; Roberts 1986).
The origin of the left coronary artery from the right sinus of Valsalva coursing between the aorta
and the pulmonary artery (preaortic) is the most threatening of these abnormalities and has been
associated with myocardial infarction and sudden death with physical exertion in young adults
(Taylor et al. 1992; Kragel and Roberts 1988). While compression between the great vessels is
a mechanism for ischemia, the mechanism for sudden cardiac death appears more related to the slit-
like narrowing of the ostial left main due to its acutely angulated leftward takeoff from the right sinus
of Valsalva. The intraseptal course has been associated with ischemic complications, though the
other anomalous courses of the left coronary artery seem more benign (Cheitlin et al. 1974). The
LAD origin can arise anomalously from the right sinus of Valsalva or RCA, often associated with
transposition of the great vessels or tetralogy of Fallot.
The right coronary artery originating from the left sinus of Valsalva or proximal left main most
always courses retroaortic (between the great vessels) and is variable in its ischemic presentations
(Yamanaka and Hobbs 1990; Shirani and Roberts 1993; Fig. 38).
Coronary Anomalies Without Hemodynamic Significance

These coronary anomalies have an incidence of 0.3–1.0 % (Cielinski et al. 1993). Most of these
anomalies represent an unusual location of the coronary ostium, which may make intubating these
arteries for coronary angiography more challenging, but do not seem to affect survival (Chaitman
et al. 1976; Engel et al. 1975).
The anomalous origin of the left circumflex from the right sinus of Valsalva or the RCA is the most
common (Fig. 38). This anomaly should be suspected when (1) there is an unusually long left main
trunk without side branches supplying the lateral myocardium, or (2) during left ventriculography in
30 RAO, the LCx is seen taking a retroaortic course, seen “on end” posterior to the aorta as
a radiopaque dot (Page et al. 1974; Serota et al. 1990). Selective right coronary angiography may
miss this anomaly if the tip of the catheter is beyond the anomalous LCx origin. The anomalous LCx
is often easily engaged with an Amplatz right or multipurpose catheter.
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A
Ostium
Ostium
RCA
RCA
RAO
LAO
B-1 B-3
ectopic origin
of LCx from right cusp
LCA
B-2 LCX
Fig. 38 Anomalous coronary artery origins. (a) Anomalous right coronary artery (RCA) origin from the left sinus of
Valsalva. Selective coronary angiography required an Amplatz left diagnostic catheter. In the right anterior oblique
(RAO) projection, the slit-like origin (red arrows) demonstrates the course between the pulmonary artery and aorta and
associated compression. This patient required surgical correction for relief of symptoms. (b) Anomalous left circumflex
(LCx) origin from right sinus of Valsalva. B-1 demonstrates the long left main coronary artery (LCA), which is often
a clue. B-2 demonstrates the “aortic root sign” (or “dot sign”) of the anomalous left circumflex in cross section send
during RAO ventriculography. B-3 demonstrates the ectopic origin just adjacent to the RCA during selective coronary
angiography (Reproduced with permission from Dr. Windecker, Panvascular Medicine, 1st edn, Lanzer P (ed) chapter
47, Springer 2002)
The anomalous origin of either the right or left main coronary artery from the noncoronary cusp is
extremely rare, more frequently reported to be the right (Roberts 1986; Cielinski et al. 1993). This
rarely has increased ischemic consequence.
Single coronary arteries are defined as a single aortic ostium giving rise to a common mixed trunk;
however, there are many permutations (Lipton et al. 1979). A separate ostium from the right sinus of
Valsalva for the conus branch may coexist (Fig. 25b). Lipton et al.’s classification remains the most
commonly used. The letters R and L indicate whether the common mixed trunk arises from the right
or left sinus of Valsalva. The letters A, B, and P denote the course of the artery, anterior, between, or
posterior to the great vessels, respectively. When found in young patients, single coronary arteries
are associated with other cardiovascular abnormalities (Lipton et al. 1979). Coronary perfusion
appears preserved, and this anatomy does not seem to predispose to premature atherosclerosis;
however, development of coronary stenosis in the common mixed trunk can have devastating
consequences.
Other variations in coronary anatomy are of little significance. The location of the coronary ostia
can be variable. The right coronary ostium seems more variable, with a takeoff below the aortic ring
defined as low and more than 1 cm above the sinotubular junction defined as high.
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Table 13 Major complications during coronary angiography

Patients Myocardial
Study Year (n) Death infarction Stroke Vascular Arrhythmia Any
CASS (Davis et al. 1979) 1979 7,553 0.20 % 0.25 % 0.03 % 0.74 % 0.63 % 1.85 %
SCAI (Kennedy 1982) 1982 53,581 0.14 % 0.07 % 0.07 % 0.57 % 0.56 % 1.41 %
Wyman (Wyman 1988) 1986 1,609 0.12 % 0.0 % 0.1 % 1.6 % – 1.82 %
SCAI (Johnson et al. 1989) 1989 222,553 0.10 % 0.06 % 0.07 % 0.46 % 0.47 % 1.16 %
SCAI (Noto et al. 1991) 1991 59,792 0.11 % 0.05 % 0.07 % 0.43 % 0.38 % 1.04 %
Amman (Ammann et al. 2003) 2003 7,412 0.0 % 0.0 % 0.11 % 0.20 % 0.13 % 0.80 %
NCDR (Dehmer et al. 2012)a 2012 1,091,557 0.6 % – 0.17 % 0.49 % – 1.35 %
CASS Coronary Artery Surgery Study, SCAI Society of Coronary Angiography and Interventions, NCDR National
Cardiovascular Data Registry
a
Diagnostic catheterization only patients without ST elevation myocardial infarction
The ostium for the conus branch may be separate from the right coronary artery; the conus branch
may provide an important collateral to an occluded LAD (termed Vieussens’ collateral). One should
avoid injecting a full complement of contrast into a small conus branch, as ventricular fibrillation
may result. Separate ostia for the LAD and LCx occur in anywhere from 0.5–8 % of angiograms
(Dicicco et al. 1982). In the case of separate ostia for the LAD and LCx, a JL 4.0 may selectively
engage the LAD, while a larger Judkins catheter or an Amplatz catheter may be required to selectively
engage the LCx ostium, as previously discussed.
Myocardial “bridging” refers to phasic systolic compression of a segment of artery that travels
within the myocardium. The mid-segment of the LAD is most often involved. While there are
reports of angina and anterior wall ischemia during tachycardia, it is largely felt to be a benign
finding given that the majority of coronary perfusion occurs during diastole, when there is no
compression.
Complications
Despite increasing complexity and morbidity of patients undergoing coronary angiography, the rate
of major cardiac and cerebrovascular complications (MACCE) following diagnostic coronary
angiography remains low (Bashore et al. 2012; Dehmer et al. 2012; King III et al. 1998; Roe
et al. 2010; Table 13). Major complications associated with coronary angiography include death,
myocardial infarction, cerebrovascular accident, arrhythmias, vascular access site complications,
contrast material reactions, hemodynamic complications, and perforation of cardiac chambers. The
occurrence of major complications during coronary angiography depends on the clinical condition
of the patient and may be predicted by several parameters (Table 14) prior to the procedure. In
a multivariate model, moribund status of the patient, acute myocardial infarction <24 h, renal
insufficiency, cardiomyopathy, and valvular heart disease were associated with significantly higher
procedural complications (Scanlon et al. 1999; Laskey et al. 1993; Table 15). Aside from patient-
related factors, operator experience also has been shown to be an important determinant of
procedural complications (Ammann et al. 2003).
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Table 14 Risk factors for increased morbidity associated with coronary angiography
Increased medical risk
Morbid obesity
Cachexia
Renal insufficiency
Uncontrolled glucose intolerance
Uncontrolled hypertension
Increased cardiovascular risk
Acute coronary syndromes
Acute myocardial infarction
Three-vessel coronary artery disease
Left main coronary artery disease
Heart failure classes III–IV
Significant valvular heart disease
Severely diminished left ventricular function
Complex congenital heart disease
Severe peripheral vascular disease
Recent cerebrovascular accident
Table 15 Multivariate predictors of major complications of coronary angiography

Variable Odd ratio 95 % confidence interval
Moribund 10.22 3.77–7.76
Shock 6.52 4.18–10.18
Acute MI <24 h 4.03 2.61–6.21
Renal insufficiency 3.30 2.39–4.55
Cardiomyopathy 3.29 2.23–4.86
Aortic valve disease 2.72 2.02–3.66
Mitral valve disease 2.33 1.76–3.08
Congestive heart failure
Class I 1.0
Class II 1.15 0.94–1.41
Class III 1.32 0.92–1.51
Class IV 1.52 1.16–1.74
Hypertension 1.45 1.22–1.73
Unstable angina 1.42 1.16–1.74
Outpatient/inpatient 0.63 052–0.76
MI myocardial infarction
Death (0.10–0.60 %)
The mortality related to coronary angiography is less than 0.6 % and therefore quite low and has
been remarkably constant over several decades, despite a proportional increase in older and
seriously ill patients. Several risk factors predicting an increased mortality with coronary angiogra-
phy have been identified, including left main or severe three-vessel coronary artery disease, severely
diminished left ventricular function (LVEF <30 %), advanced heart failure (NYHA class IV), and
severe valvular heart disease (Noto et al. 1991; Table 16). The use of heparin has been investigated in
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Table 16 Risk factors for increased mortality with coronary angiography

Clinical characteristics Mortality
Overall 0.1 %
Age
<1 year old 1.75 %
>60 year old 0.25 %
Coronary artery disease
One vessel 0.03 %
Three vessels 0.16 %
Left main 0.86 %
Heart failure
NYHA class I or II 0.02 %
NYHA class III 0.12 %
NYHA class IV 0.67 %
Valvular heart disease
Mitral valve disease 0.34 %
Aortic valve disease 0.19 %
NYHA New York Heart Classification
the CASS study, and there was no difference in mortality in patients receiving heparin (0.16 %)
compared to patients not receiving heparin (0.18 %) (Davis et al. 1979).
Coronary Ischemia and Myocardial Infarction (0.05–0.06 %)

Ischemia that develops during coronary angiography is observed in patients with severe coronary
artery disease or acute coronary syndromes, inflicted by the temporary occlusion of the coronary
ostium (LM stenosis or ostial RCA) or the displacement of coronary blood flow by contrast material.
Removal of the catheter tip from the coronary ostium and deferral of the following contrast injection
usually suffice to resolve ischemia in this situation. In case of persistent ischemia, intravenous
nitroglycerin (or 100–250 mcg intracoronary) and beta-blockers may be administered. The diagno-
sis of a myocardial infarction requires elevated cardiac biomarkers or ECG changes within 24 h of
the procedure. True myocardial infarction during coronary angiography is exceedingly rare and has
been reported in 0.05–0.06 % of patients. Catheter-induced myocardial infarction may be related to
prolonged vasospasm, coronary artery dissection, and thrombotic occlusion. These complications
can be immediately corrected in the majority of cases by removing the catheter from the ostium,
stenting of flow limiting dissections, and aspiration and recanalization of thrombotic occlusions.
Cerebrovascular Complications (0.03–0.17 %)

Cerebrovascular complications of stroke and transient ischemic attack during coronary angiography
are related to embolization of air, thrombus, or atherosclerotic debris into the cerebral circulation
(Segal et al. 2001; Hamon et al. 2008; Werner et al. 2012). Potential sources are thrombus deposition
on the catheter and guidewires utilized during the examination, as well as dislodgment of material
from the left ventricular cavity (e.g., left ventricular apical thrombus) or ascending aorta. Precautions
to avoid these complications include careful evacuation of air from the catheters, short catheter and
guidewire times in the circulation, and the utilization of heparinized flushing solutions. Exchange of
catheters in the descending instead of the ascending aorta may further reduce the risk of embolic
stroke. Diabetes mellitus, hypertension, prior stroke, use of intra-aortic balloon pump, and urgent
coronary angiography are independent risk factors for stroke. There are limited but promising data
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Table 17 Vascular complications of coronary angiography

Bleeding
Hematoma
Retroperitoneal bleeding
Pseudoaneuryms
Arteriovenous fistula
Arterial dissection
Vessel rupture
Local infection
Distal embolism
Vessel thrombosis
Peripheral neuropathy
Vascular closure device complications
Fig. 39 Pseudoaneurysm. Pseudoaneurysms are commonly diagnosed by ultrasound. (a) The artery (yellow solid
arrow), pseudoaneurysm neck (white arrow), and pseudoaneurysm (yellow dashed arrow) are depicted here. (b)
Demonstrates the pathognomonic bidirectional (“to-and-fro”) flow of a pseudoaneurysm neck. (c) These can be treated
via percutaneous injection of thrombin. A thrombosed pseudoaneurysm (yellow dashed arrow) is depicted after
successful thrombin injection (Courtesy of Dr. Sanjay Gandhi, Case-Western Reserve, MetroHealth, Cleveland, OH)
on the use of early intra-arterial thrombolytic therapy or mechanical thrombectomy in patients with
periprocedural stroke (Hamon et al. 2008; Werner et al. 2012).
Vascular Access Site Complications (0.4–1.0 %)

Vascular access site complications are the most common adverse event of coronary angiography
(Table 17). Femoral access is associated with significantly higher incidence of vascular complica-
tions compared to radial access (Jolly et al. 2009). Complications unique to radial artery access site
are discussed separately.
Bleeding at the local sheath insertion site can result in hematoma or pseudoaneurysm (PSA)
formation. While majority of hematomas are small and managed with conservative therapy and local
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compression, large or expanding hematoma leading to compartment syndrome may necessitate

surgical evacuation. In addition, large hematomas can result in femoral neuropathy and deep venous
thrombosis by direct compression of the femoral nerve or vein, respectively. Careful attention to
detail while gaining access (e.g., entry point at the common femoral artery and single wall puncture)
and proper compression or deployment of appropriate closure device and bed rest post sheath
removal are important to minimize risk for local bleeding complications. Older age, female sex,
overweight or underweight patients, presence of peripheral vascular disease, renal failure, large
sheath size, and use of anticoagulation are independent predictors of increased risk for vascular
complications (Applegate et al. 2008).
Unlike a hematoma, PSA is characterized by direct communication between the arterial lumen
and the PSA sac and is best identified on vascular duplex examination (Fig. 39). It may present as
a pulsatile mass, localized bruit, or symptoms related to compression of femoral nerve or vein. Small
PSA (<3 mm) in patients not on anticoagulation may close spontaneously (Samal and White 2002;
Toursarkissian et al. 1997). Larger PSA can be managed with local ultrasound compression or
ultrasound-guided thrombin injection with high rate of success. In patients with large PSA with
broad neck or failure of thrombin injection, surgical repair may be considered (Samal and White
2002).
Arteriovenous (AV) fistulae represent iatrogenic communication between femoral artery and
vein. Low puncture of the femoral artery is associated with increased risk for development of AV
fistula. Most of AV fistula are asymptomatic and can be detected by continuous murmur or palpable
thrill. The diagnosis is easily confirmed by vascular duplex. Large AV fistulae may lead to high
output state. Small AV fistulae do not require intervention. Large AV fistulae can be repaired
surgically though there are some reports of successful use of covered stents in these patients
(Samal and White 2002).
Retroperitoneal bleeding is rarely observed after cardiac catheterization but can be potentially
life-threatening (Samal and White 2002; Kent et al. 1994a; Farouque et al. 2005; Ellis et al. 2006;
Tiroch et al. 2008). It is generally caused by arterial puncture above the inguinal ligament or
bleeding from a branch vessel. Risk factors for retroperitoneal bleeding include female gender,
active anticoagulation, and low platelet count. Symptoms and physical examination findings
suggestive of retroperitoneal bleeding include severe back and lower quadrant pain, suprainguinal
tenderness and mass, and femoral neuropathy. However, these symptoms and signs may manifest
late; thus, given its associated morbidity and mortality, hypotension post-procedure should be
presumed retroperitoneal bleeding until proven otherwise. While a decrease in hematocrit is also
suggestive, this is also a delayed manifestation. Retroperitoneal bleeding can be confirmed with
abdominal ultrasound or non-contrast CT scan; however, these tests should be performed only after
ensuring hemodynamic stability. Most patients can be treated conservatively by cessation of
anticoagulation, fluid resuscitation, and blood transfusions. In patients with ongoing hemodynamic
instability, endovascular balloon tamponade of the iliac artery or coil embolization of bleeding
branch vessel or surgical exploration can be considered (Samal and White 2002).
Femoral or iliac artery dissection during coronary angiography may be caused by injury with the
wire or catheters. Early recognition is important and since the dissections are retrograde, non-flow-
limiting dissections usually can be managed with removal of the catheters and manual compression.
Flow-limiting or occlusive dissections can be managed by endovascular stent/angioplasty via
ipsilateral or contralateral approach (Samal and White 2002; Fig. 40).
Thrombosis of femoral artery access site is unusual and rarely leads to acute limb ischemia. More
commonly, it may be associated with distal embolization. Careful attention to sheath flushing is
important to avoid this complication. Thrombotic occlusion of the femoral artery can be managed
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Fig. 40 Vascular access Dissection. (a) Flow-limiting dissection of the right external iliac artery is demonstrated
angiographically. (b) Resolution of dissection after self-expanding stenting from contralateral access (Courtesy of
Dr. Sanjay Gandhi, Case-Western Reserve, MetroHealth, Cleveland, OH)
with catheter-directed thrombectomy/thrombolysis or surgical embolectomy (Samal and White

2002).
Femoral neuropathy following coronary angiography is probably related to nerve compression or
traction from a local hematoma or direct needle injury (Kent et al. 1994b).
Vascular closure devices (VCDs) are frequently used for femoral access site closure. There are
several devices including extravascular collagen plugs, sutures, and clips. While these devices allow
for early ambulation, there are conflicting data on reduction in vascular complications with the use of
these devices (Nikolsky et al. 2004; Samal and White 2002; Vidi et al. 2012; Koreny et al. 2004;
Nikolsky et al. 2004; Biancari et al. 2010). Vascular bleeding related to device failure – especially in
anticoagulated patients – is the most common issue. In addition, there may be a slight increase in risk
for local infection especially with suture devices, and the collagen plugs can lead to distal embo-
lization of the plug. Careful deployment of the device and attention to aseptic techniques can
minimize the risk for these complications.
Cholesterol Emboli Syndrome (0.15 %)

The cholesterol emboli syndrome is a rare complication following angiographic procedures. The
true incidence is difficult to determine, but cholesterol emboli have been suspected clinically in
0.15–1.4 % of patients undergoing left heart catheterization (Patel et al. 2010; Drost et al. 1984).
Risk factors for the cholesterol emboli syndrome include diffuse atherosclerosis, arterial catheter-
ization, arterial surgery, male gender, and possibly fibrinolysis and anticoagulation. The injury
appears related to the embolic occlusion of small peripheral arteries with cholesterol-rich fragments
of spontaneously or iatrogenically ruptured plaques of large arteries (mostly the aorta). The clinical
manifestations of the cholesterol emboli syndrome are numerous, may be acute or insidious, and
encompass visual disturbances, pain, numbness and paralysis of extremities, abdominal and back
pain, skin discoloration (livedo reticularis, blue toes), renal insufficiency, and gangrene. Laboratory
findings consist of leukocytosis with eosinophilia, anemia, and an elevated erythrocyte sedimenta-
tion rate. The diagnosis is established by fundoscopy (Hollenhorst plaques), skin biopsy of an
affected area (livedo), or bone marrow biopsy. Patients are treated supportively and the prognosis
is poor (Fukumoto et al. 2003).
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Arrhythmias (0.05 %)
Significant arrhythmias requiring therapeutic intervention are observed in less than 0.05 % of
patients. Asystole or transient atrioventricular conduction defects are usually short lasting and
contrast mediated, particularly following prolonged contrast injections into the RCA. Forceful
coughing not only maintains a sufficient perfusion pressure but also accelerates resumption of
normal sinus and AV node function. However, this complication has become rare with the advent of
low-osmolar contrast agents. Sustained ventricular tachycardia is exceedingly rare and usually
observed in patients with an old infarction and diminished left ventricular function. In contrast,
reperfusion arrhythmias and idioventricular tachycardia are frequently seen in the setting of primary
percutaneous interventions for acute myocardial infarction. The typical profile of a patient devel-
oping ventricular fibrillation during coronary angiography is characterized by normal left ventricular
function, injection into the RCA, and onset approximately 10 s after completed injection. Injection
of contrast material with a catheter occluding a coronary ostium by means of a deeply engaged
catheter or the presence of an ostial lesion may also result in ventricular fibrillation, which requires
prompt termination by defibrillation.
Air Embolism
Inadvertent injection of air into the coronary arteries results in temporary ischemia and may become
manifest as hypotension, arrhythmias, or myocardial infarction. Injected air appears angiographic-
ally as radiolucent bubbles, which travel with the blood stream during contrast injection from
proximal to distal, or slow contrast flow and washout with greater amounts of air injection. Small
amounts of air are usually silent, whereas larger amounts may cause ST elevation and chest pain
mimicking myocardial infarction. Air embolism should be treated with thorough flushing of the
affected coronary artery with saline or vasodilators to dissipate the trapped air.
Coronary Artery Dissections

Coronary artery dissections inflicted by diagnostic angiography catheters have become much less
common since the introduction of small catheters with soft tips. They are mostly observed in
severely atherosclerotic vessels or in case of inadvertent deep catheter intubation. Catheters with
the potential for deep intubations such as the Amplatz and multipurpose catheter are suspected to
result in a higher incidence of dissection. The extent of the dissection, the impact on coronary blood
flow, and the dependent myocardial territory determine the therapeutic avenue. Small dissections
without significant contrast retention heal spontaneously, whereas an extensive dissection of the left
main coronary artery requires prompt treatment by placement of a coronary artery stent or CABG.
Vasovagal Reactions
Vasovagal reactions are mostly related to painful vascular access or sheath manipulations and
manifest as hypotension, bradycardia, nausea, and vomiting. Especially in the elderly, vasovagal
reactions may be predominantly vasodepressive in nature without accompanying bradycardia.
Vasovagal reactions respond rapidly to volume expansion (elevating legs, intravenous fluid bolus)
and intravenous atropine. In patients with severe aortic stenosis or significant left main stenosis,
protracted hypotension may be life-threatening and must be treated expeditiously.
Contrast-Induced Nephropathy
Initial contrast agents had high osmolality and were associated with more frequent hemodynamic
and electrophysiologic consequences, in addition to flushing, pain, and gastrointestinal symptoms.
Second-generation contrast agents are lower osmolality and include both ionic and nonionic agents.
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Risk Factors Integer Score

Hypotension 5
IABP 5
Risk Risk of Risk of
5 Score CIN Dialysis
CHF
Age >75 years 4 ≤5 7.5% 0.04%
Anemia 3
6 to 10 14.0% 0.12%
Diabetes 3 Calculate
Contrast media volume 1 for each 100 cc3 26.1% 1.09%

11 to 16
Serum creatinine>1.5mg/dl 4
OR 2 for 40 - 60 ≥ 16 57.3% 12.6%
eGFR <60 ml/min/1.73 m2 4 for 20 - 40

2
eGFR (ml/min/1.73 m )= 6 for < 20
-1.154
186 × (SCr) × (Age)-0.200
× (0.742 if female) × (1.210
if African American )
Fig. 41 Mehran risk score for contrast-induced nephropathy (Reprinted with permission from Rightslink from
Mehran et al. (2004))
Data of varying quality do not clearly support universal use; however, patient comfort and reports of
reduced anaphylactoid reactions, and the logistics of using a single agent, have led to the widespread
use of lower osmolar contrast agents. Suggestion of variable effects on coagulation is unproven.
A single third-generation agent, iodixanol, has the lowest osmolality; however, the incidence of
adverse events is similar. Injection of iodixanol is associated with less discomfort during intracranial
and peripheral arterial angiography than earlier generation agents.
Contrast-induced acute renal injury or nephropathy (CIN) after coronary angiography is
often of greatest concern. CIN is caused by renal vasoconstriction or direct cytotoxicity of the
contrast agent and is generally reversible. Risk factors of CIN include diabetes mellitus, preexisting
renal insufficiency, and higher volume of contrast agent. Figure 41 demonstrates a validated risk
score to predict the incidence of CIN and dialysis (Mehran et al. 2004). The serum creatinine rises
generally in 24–48 h and begins to decline in 3–7 days. While several different strategies have been
tried to minimize risk for CIN, hydration with normal saline 3–12 h before and 6–24 h after the
procedure and use of least amount of contrast have been consistently shown to reduce the incidence
of CIN (Rudnick et al. 1995; Schwab et al. 1989; Solomon et al. 1994; Maioli et al. 2008; Alonso
et al. 2004; Vasheghani-Farahani et al. 2009; Brar et al. 2009; Zoungas et al. 2009; Klima et al. 2012;
Kay et al. 2003; Marenzi et al. 2006) and is recommended by current guidelines (Anderson
et al. 2013). There are conflicting data on the use of sodium bicarbonate infusion compared to
normal saline alone (Bashore et al. 2012; Solomon et al. 1994; Maioli et al. 2008; Alonso et al. 2004;
Vasheghani-Farahani et al. 2009; Brar et al. 2009; Zoungas et al. 2009) and current guidelines do not
support its use over isotonic crystalloid (Anderson et al. 2013). Similarly, while the initial studies
showed a benefit of N-acetylcysteine in reducing CIN (Klima et al. 2012; Kay et al. 2003), a recent
randomized trial (acetylcysteine for the prevention of contrast-induced nephropathy, ACT) of 2,308
patients undergoing angiography using 1,200 mg twice a day dose of acetylcysteine did not show
any benefit (ACT Investigators 2011) and current guidelines do not recommend its use (Anderson
et al. 2013).
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Complications of Radial Catheterization

Complications of Radial Versus Femoral Artery
Radial access for coronary angiography has been associated with significantly lower risk for access
site complications than femoral access (Jolly et al. 2009, 2011; Kanei et al. 2011; Pancholy 2009;
Joyal et al. 2012). This is especially true in patients with an acute coronary syndrome undergoing
coronary angiography and intervention. In the largest randomized study (RadIal Vs femorAL access
for coronary intervention, RIVAL) (Jolly et al. 2011), 7,021 patients were randomized to radial
versus femoral access. While there was no significant difference in the primary end point of death,
myocardial infarction, stroke, or non-CABG-related major bleeding at 30 days (3.7 % in radial
group versus 4.0 % in femoral group; p ¼ 0.50), the radial approach was associated with a signif-
icantly lower rate of major vascular complications (1.4 % versus 3.7 %; p < 0.0001). In a meta-
analysis of ten randomized trials of patients with acute ST elevation myocardial infarction, radial
access use was associated with improved survival and reduced local vascular complications (Joyal
et al. 2012). Similar improvement in survival was seen in the patients with ST elevation MI in the
Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome
(RIFLE-STEACS) trial and in the subgroup of STEMI patients in the RIVAL study (Mehta
et al. 2012; Romagnoli et al. 2012).
Radial Artery Injury and Occlusion

Asymptomatic radial artery occlusion following radial access occurs in 2–18 % of patients and is
associated with the use of larger sheath size, multiple catheter exchanges, repeat access, prolonged
high pressure compression, and inadequate anticoagulation (Kanei et al. 2011; Pancholy 2009; Rao
et al. 2012). The occlusion of radial artery is likely related to thrombus formation and possible
intimal injury with neointimal hyperplasia (Pancholy 2007; Yonetsu et al. 2010). Fortunately, due to
collateral circulation, most of these are asymptomatic and are rarely associated with acute hand
ischemia. However, radial artery occlusion may lead to inability to use radial artery for subsequent
procedures or precludes its use as a conduit for coronary artery bypass graft. Routine use of heparin
is generally recommended to minimize the risk of radial artery occlusion (Pancholy 2009). In
patients undergoing coronary intervention, bivalirudin showed similar efficacy as heparin in
preventing radial artery occlusion (Plante et al. 2010). Patent hemostasis has also been shown to
decrease the risk of radial artery occlusion (Pancholy et al. 2008).
Use of 5 F sheaths, early administration of anticoagulation after placing the sheath (heparin or
bivalirudin for known percutaneous coronary intervention), and the use of patent hemostasis rather
than occlusive compression can all reduce the rate of radial arterial occlusion.
Local Bleeding Complications

Bleeding complications are rare after transradial catheterization (Fig. 42). The injuries to the radial
artery that can result in bleeding include avulsion, dissection, or perforation (Bertrand et al. 2009).
A classification of hematoma in the arm has been reported based on the Early Discharge After
Transradial Stenting of Coronary Arteries (EASY) trial (Bertrand et al. 2006). Grade I hematomas
occur in 5 % of patients and are defined as <5 cm. These can be treated with analgesia and additional
compression bracelets. Grade II hematoma are defined as hematoma with moderate muscle infiltra-
tions and are <10 cm in length. These occur in <3 % of cases and can be treated similar to grade
I hematoma. Grade III hematomas involve muscle infiltration below the elbow and occur in <2 % of
cases. A blood pressure cuff may be inflated at 20 mm <systolic blood pressure, with frequent
deflations every 15 min to contain bleeding. Grade IV hematomas occur in <0.1 % and extend above
the elbow. Grade V hematoma cause limb threat by causing compartment syndrome and occur in
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Fig. 42 Transradial bleeding complication. Bleeding complications are rare with transradial arterial access.
A forearm hematoma is shown here. These can often be treated conservatively, with very careful attention to
compartment syndrome, which is a surgical emergency (Courtesy of Dr. Sanjay Gandhi, Case-Western Reserve,
MetroHealth, Cleveland, OH)
Fig. 43 Arteriovenous fistula. The characteristic arterialization of the venous waveform on duplex proves the presence
of a radial arteriovenous fistula (Courtesy of Dr. Sanjay Gandhi, Case-Western Reserve, MetroHealth, Cleveland, OH)
<0.01 % of cases. In a large series of >50,000 radial cases, there were only two cases of
compartment syndrome (<0.004 %) (Tizon-Marcos and Barbeau 2008). These require prompt
surgical decompression for limb salvage. Rare occurrences of pseudoaneurysm formation and
arteriovenous fistula (Fig. 43) have been described as well (Sanmartín et al. 2004). The PSA can
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be treated with ultrasound-guided compression, thrombin injection, or surgical ligation (Kanei

et al. 2011).
Sterile Granuloma Formation

Subramanian et al. first described sterile granuloma with Cook™ (Bloomington, IN) radial sheath in
2003 resulting in local necrosis and giant cell reaction (Subramanian et al. 2003). This is a rare
complication seen in 2.8 % of cases and seems to be specific to the hydrophilic coating in Cook™
sheaths (Kozak et al. 2003) and has not been described with the use of other hydrophilic sheaths.
This should be recognized and differentiated from an infected pseudoaneurysm, as sterile granulo-
mas are usually transient, self-limited phenomena, which need local skin care and no further
treatment.
Conclusions
Despite the advent of noninvasive imaging modalities to assess the coronary arteries (e.g., computed
tomographic angiography), diagnostic coronary angiography remains the gold standard for the
anatomic assessment of the coronary arteries. Rather than replace the use of diagnostic coronary
angiography, advanced noninvasive imaging has been incorporated into cardiac catheterization
laboratories. Hybrid imaging platforms combine invasive angiography and noninvasive imaging
to facilitate safer and more time-effective advanced procedures.
Moreover, the use of radial arterial access and the continued miniaturization of sheath and catheter
size have reduced the risk of performing more complex procedures. For example, the use of 4 F
radial arterial access has become standard in some cardiac catheterization labs around the world.
Dual radial arterial access is being used to treat complex chronic total occlusions in some high-
volume centers.
Despite studies that have raised debate over the most appropriate use of percutaneous coronary
intervention, diagnostic coronary angiography remains an essential tool in cardiovascular medicine,
and the horizon for catheter-based cardiovascular procedures remains bright. Expertise in coronary
angiography and catheter-based interventions has advanced treatments in other cardiovascular
fields, increasing percutaneous treatment strategies for vascular and structural heart disease, in
particular. Whereas coronary angiograms used to be the sole procedures of many cardiac catheter-
ization laboratories, many cath labs today are performing increasing percentages of noncoronary
angiograms and advanced structural heart procedures.
Acknowledgments
The authors would like to thank Drs. Stephan Windecker and Bernhard Meier, whose Chapter X-Ray
Coronary Angiography served as the foundation for this chapter, and from which some sections are
excerpted. Permission to reprint certain figures was greatly appreciated from Dr. Stephan
Windecker.
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PanVascular Medicine

Diagnostic Coronary Angiography

Normal Coronary Anatomy

Left pulmonary veins

Interventricular plane Atrioventricular

Left Coronary Artery

Right Coronary Artery

Indications for Coronary Angiography

Patient and Operator Preparation

Table 1 “Appropriate” indications for diagnostic catheterizationa

Table 2 Management of anticoagulants for diagnostic coronary angiography

antihistamine prophylaxis. Current recommendations are prednisone 50 mg 13 h, 7 h, and 1 h prior

Table 3 Contraindications to cardiac catheterization and strategies to address

Vascular Access Considerations

Table 4 Advantages and disadvantages of radial access versus femoral access

Radial Artery Compression

Pitfalls to Radial Arterial Access: Spasm, Radial Loops

Right Versus Left Radial Access

Table 5 Conversion table for French size

Judkins Catheters Amplatz Catheters Multipurpose Catheter

Table 6 Common catheters for coronary arteries and bypass grafts

Aortic Bypass Graft Catheterization

Internal Mammary Catheterization

RAO 20, Caudal 20

Gastroepiploic Artery Catheterization

Right Gastroepiploic Artery

Gastroduodenal Hepatic Artery

Right Anterior Oblique

Left Anterior Oblique

RAO 20, Cran 20 AP, Cran 30 LAO 30, Cran 30

RAO 20, Caud 20 AP, Caud 30 LAO 30, Caud 30

Anteroposterior and Lateral Projections

Bypass Graft Angiography

Table 7 Angiographic angles for specific vessels

Coronary Angiographic Interpretation

% stenosis ¼ ðminimal lumen diameter at stenosis site=reference diameterÞ  100

Table 8 ACC/AHA lesion morphology

Table 9 TIMI assessment of perfusion

Table 10 TIMI myocardial perfusion grade

Corrected TIMI Frame Count (CTFC)

TIMI Myocardial Perfusion Grade (TMPG)

Table 11 Nomogram describing the global risk classification

EuroScore SYNTAX score

Quantitative Coronary Angiographic Interpretation

Pitfalls of Coronary Angiography

Coronary Collateral Circulation

Coronary Artery Anomalies with Hemodynamic Significance

Table 12 Assessment of coronary collateral perfusion

Ectopic Origin of Coronary Arteries from the Pulmonary Trunk

Congenital Stenosis or Atresia of the Coronary Arteries

Ectopic Origin of Both Coronary Arteries from the Same Sinus

Coronary Anomalies Without Hemodynamic Significance

Table 13 Major complications during coronary angiography

Table 15 Multivariate predictors of major complications of coronary angiography

Table 16 Risk factors for increased mortality with coronary angiography

Coronary Ischemia and Myocardial Infarction (0.05–0.06 %)

Cerebrovascular Complications (0.03–0.17 %)

Table 17 Vascular complications of coronary angiography

Vascular Access Site Complications (0.4–1.0 %)

compression, large or expanding hematoma leading to compartment syndrome may necessitate

with catheter-directed thrombectomy/thrombolysis or surgical embolectomy (Samal and White

Cholesterol Emboli Syndrome (0.15 %)

Coronary Artery Dissections

% stenosis ¼ ðminimal lumen diameter at stenosis site=reference diameterÞ 100