Angiographic Views For Coronary Angiography

Copyright Medinews (Cardiology) Limited Reproduction Prohibited
INTERVENTION
Optimal angiographic views for

invasive coronary angiography:

a guide for trainees
Copyright Medinews
Peregrine Green, Paul Frobisher, Steve Ramcharitar
(Cardiology) Limited
T he ability to perform invasive diagnostic complete visualisation of each part of the coronary
Authors vasculature. This enables a thorough, complete study
coronary angiography is a core
Peregrine Green to be carried out, but crucially it also aids optimisation
Cardiology Specialty Registrar requirement for cardiologists and fellows in
training programmes. However, although key of images in the event that a lesion is found. Finally,
Paul Frobisher
Reproduction Prohibited
Superintendent Radiographer, to their independence is the ability to obtain knowledge of how to obtain optimal images allows
Cardiology Catheter Laboratories high-quality images that allow visualisation of operators to limit the number of acquired projections to
Steve Ramcharitar the entire coronary vasculature, there exists give sufficient diagnostic information while maintaining
Consultant Cardiologist the principle of ALARA (‘as low as reasonably
no formal systematic method or teaching
Wiltshire Cardiac Centre, Great achievable’) in relation to radiation exposure. We
aid. This article provides an overview of the
Western Hospital, Marlborough
Road, Swindon, SN3 6BB radiological equipment used in the catheter hope that this will be an essential aid to cardiology
laboratory, details the naming of the different trainees/fellows when they first start learning invasive
Correspondence to: angiographic projections, and gives key diagnostic angiography, as well as to other healthcare
Dr S Ramcharitar tips and tricks to improve image quality. In professionals.
(steve.ramcharitar@gmail.com)
addition, the coronary vasculature is broken
down into segments, with descriptions Overview
Key words provided of the essential views required to Equipment
angiography, invasive coronary image each one. Using this approach, it aims
angiography, views There has been tremendous progress in coronary
to provide an essential aid to trainees and
angiography since the early days, when the X-ray
Copyright Medinews
doi: 10.5837/bjc.2016.028
other healthcare professionals at the start of
emitter was manoeuvred around the patient in a
their careers.
Br J Cardiol 2016;23:110–3 cradle. Although this allowed images in the transverse
Introduction plane, wedges were needed to ‘prop’ the patient up
for any cranial angulation. Today, the modern catheter
Invasive diagnostic coronary angiography is a core
laboratory equipment consists of a radiological ‘C-arm’
procedure that all cardiology trainees/fellows are
to overcome this early limitation. In simple terms, this
required to learn, and in which they are expected to
consists of an X-ray emitter at one end of a ‘C’-shaped
become independent in practising during their training.1
arm, with an image intensifier at the other end of the
Learning normally starts during the first year, and a key
‘C’. The whole C-arm is mobile, therefore, allowing it
component of independence is the ability to take high-
to be moved around the patient to obtain views from
quality images that are sufficient to image the entire
multiple different angulations (figure 1). Latterly, direct
coronary tree, without unnecessary contrast media and
digital flat detectors have replaced image intensifiers,
radiation use. This requires good technical skills, and
improving and providing more consistent long-term
knowledge of the factors that influence image quality.
image quality. Digital imaging also allows for accurate
In addition, an understanding of the angiographic
quantitative measurements (QCA) and transfer of
projections (or radiographic views) required for
images to appropriate networks for post-processing
optimal visualisation of each section of the coronary
and, if needed, 3D reconstructions.
vasculature is vital. We present an overview of the
radiology equipment used in the catheter laboratory Two different imaging modes are available using
and details of how different projections are obtained, the C-arm; pulsed fluoroscopy (‘Fluoro’) and
together with some simple tips and tricks to optimise cinefluorographic acquisition (‘Cine’). ‘Fluoro’ provides
images. In addition, by breaking each coronary artery low-resolution real-time X-ray imaging (with resolution
up into key segments, we provide a guide to those measured in pulses/second), allowing observation
projections that are commonly required to ensure of the moving coronary tree in the two-dimensional
Volume 23 Issue 3 | July–September 2016 | The British Journal of Cardiology | 1

INTERVENTION
Figure 1. Radiological ‘C-arm’ Table 1. Comparison of average radiation Table 2. Limitations of two-dimensional
doses imaging in angiography
Procedure Typical effective doses Vessel Definition

(mSv) characteristics
Chest X-ray3 0.02 Overlapping Vessels overlying each other

in the projection, resulting in
UK average annual 2.2 interference
Copyright Medinews
background exposure3
Foreshortening Vessels seen ‘end-on’, limiting
CT chest3 3 visualisation of the entire length
CT coronary 4–21.4 Plaque Non-concentric plaque,

angiography4 eccentricity meaning lesion severity can
be misinterpreted or missed
Diagnostic invasive 2.3–22.7 altogether if only viewed from
coronary angiography4,5 Average 9.1 (approx. one angle
450 chest X-rays)
Technical Definition
Sestamibi rest–stress 11.3–14.6 characteristics
myocardial perfusion
scan4 Streaming Poor vessel opacification due
to inadequate rate of contrast
Key: CT = computed tomography media injection
Excursion Movement of vessels during

pedal placed next to the operator or radiographer, systole
with a separate pedal for each.
It is important to recognise that angiography Angiographic views
does carry significant radiation exposure, Angiographic views are classically named after
which is often not fully appreciated by all the position of both the X-ray tube and the
operators. This can lead to radiation burns intensifier (or detector) in relation to the patient.
after prolonged exposure in one view.
However, they are now commonly simplified
It is, therefore, necessary that, for long
to be named according to the position of the
procedures, angiographic views are rotated
image detector alone. When the image is taken,
to avoid this complication. The average
the name is, therefore, where the picture is
Copyright Medinews
radiation dose experienced by a patient
essentially ‘looking from’ (figure 2).
undergoing conventional diagnostic coronary
angiography, along with average doses for The main starting position is straight postero-
other radiographic procedures for comparison, anterior (PA), i.e. directly vertical to the patient’s
plane. Although image quality can be adjusted
is given in table 1.3-5 chest. From here, the ‘C-arm’ can then be moved
by increasing the radiation dose and the
in two different planes, as follows:
pulse rate (normally 10–15 pulses/second Views
in angiography), the generally low-resolution 1. Right or left anterior oblique (RAO or LAO).
Due to the differing anatomy and positions
images mean that ‘Fluoro’ is normally used for The image detector is moved to point at the
of the coronary arteries, the X-ray projection
catheter advancement and manipulation. By patient from either the right- or left-hand side,
required to obtain an optimal view changes
contrast, ‘Cine’ (with resolution measured in but still lies anterior to the patient. The degree
according to which section of each artery is
frames/second) provides images of sufficient of angulation is given as a figure, e.g. LAO
being imaged. In addition, because the images
quality for single-frame viewing. It is, therefore, 40o, often shortened to simply LAO 40. If it
obtained are two-dimensional, at least two
used to acquire the angiographic images during is moved to the same horizontal level as the
orthogonal views are normally required for
contrast media injection. Due to the dynamic patient (i.e. 90o) then the position is called
each segment to enable complete visualisation
nature of the heart and rapid flow down the right or left lateral.
and ensure that eccentric coronary stenoses
coronary arteries, frame rates of 10–15 frames/
are not missed. Indeed, the issue of using 2. Cranial (Cran) or caudal (Caud). The image
second are generally used for acquisition. ‘Fluoro’
two-dimensional images to obtain information detector is moved to point from the head or
images are, thus, moving images and are not
on a three-dimensional lumen is one of foot end of the patient, respectively. Again,
routinely stored, unless specifically requested
the key limiting factors of conventional the degree of angulation is given as a figure
or done so retrospectively by the operator after
angiography. in degrees.
acquisition. Due to the higher resolution of ‘Cine’
images, however, the radiation dose needed is Tables 2 and 3 explain the factors that can The image detector is often positioned at a
approximately 10 times that used in ‘Fluoro’.2 affect the images obtained, and how to best point that encompasses a combination of these
Activation of ‘Fluoro’ or ‘Cine’ is usually via a foot optimise these images. positions, e.g. RAO-Caudal, etc. It is commonly
2 | The British Journal of Cardiology | July–September 2016 | Volume 23 Issue 3

INTERVENTION
Table 3. Optimising images Figure 2. Naming of angiographic projections showing the two different planes from the
posterior anterior position
Technique Definition
Collimation and Collimation (or narrowing down)

filtration of the radiation beam to the
area of interest, improving image
spatial resolution and limiting
radiation dose and scattered
radiation. Use of wedge filters
Copyright Medinews
reduces glare at the heart–lung
interface
Increased frame Increasing the number of frames

rate per second (e.g. from 15 to 30
(temporal FPS) increases image quality
resolution) (but this also increases radiation
dose)
Breath holding Stabilises image and limits

movement out of the viewing
Figure 3. Three-dimensional reconstruction of coronary arteries
field. Held inspiration also
reduces radiation dose
to patient and scatter by
removing diaphragm from the
field of view
Increased Increased flow rates can improve

catheter size vessel opacification
Vasodilator use Coronary dilatation can help

(e.g. nitrates) determine the significance of a
lesion
Optimising heart Use of verapamil/beta blockers

rate and adequate sedation can
limit excursion and aid
viewing
Co-axial Choosing the correct catheter

catheter improves contrast flow and
Key: Ao = aorta; LA = left atrium; LAD = left anterior descending; LCX = left circumflex; LM = left main stem;
placement vessel opacification due to less
Copyright Medinews
LV = left ventricle; MO = obtuse marginal; RCA = right coronary artery; RVOT = right ventricular outflow tract
streaming
advised that initial cannulation of the right and 3). In general, the left main stem (LMS) comes circumflex as between OM1 and the second
left coronary ostia is attempted in LAO 40, to off the left coronary cusp and divides into the obtuse marginal (OM2) and distal circumflex as
help guide initial catheter placement and achieve left anterior descending (LAD) and left circumflex distal to this. Finally, the proximal RCA is defined
co-axial alignment. However, some operators (LCx), while the right coronary artery (RCA) as from the origin to where it becomes vertical,
prefer PA for the latter. Due to variation of comes off the right coronary cusp. The LAD runs mid as the vertical segment, and distal as from
anatomy, the choice of catheter needs to be down the anterior interventricular groove, while the end of the vertical segment to the bifurcation
suitably chosen to avoid the risk of left main the RCA and LCx normally run around the heart into posterior-descending and postero-lateral
stem dissection. Ordinarily, 6F or 5F Judkins in the atrioventricular grooves. arteries.7
right and left catheters are used for diagnostic The coronary arteries are then commonly divided Tables 4a–f gives a list of the most common
procedures. 5F catheters have the advantage into segments for ease of description. Although recommended projections for each coronary
that they are softer and, hence, less traumatic, they can be divided into 16 segments as used segment.8 Although these may well need to be
but the lower volume of contrast media extruded in the Syntax Scoring Calculator,6 for optimising adapted on a case-by-case basis, depending on
may limit the image quality. Firmer injections angiographic views we have simplified the the anatomy present, and to take into account
are needed to overcome this limitation. Breath anatomy into the well-established proximal, mid any patient-specific requirements, they represent
holding is sometimes necessary to achieve and distal segments of each coronary artery. the most commonly used projections and are a
successful cannulation, but it is good practice Proximal LAD is defined as being between the good starting point when commencing invasive
not to engage the ostia straight away but rather LMS and the first diagonal (D1).7 Mid LAD is diagnostic angiography for the first time.
perform a non-selective image if there is a from D1 to the third diagonal (D3) and distal A good standard set of views, which can,
suspicion of ostial disease. LAD is distal to D3. The LCx is often divided therefore, be taken for a straightforward, routine,
The anatomy of the coronary vasculature can be into simply proximal (from LMS to first obtuse diagnostic angiogram, and, which are likely
appreciated on 3D reconstructions of computed marginal [OM1]) and distal (distal to OM1).7 to ensure adequate visualisation of the entire
tomography (CT) coronary angiography (figure However, we have chosen to define mid coronary anatomy, is given in table 5.9 These

INTERVENTION
can then be adjusted or added to if any particular and radiation exposure per patient. However,
segment needs further assessment, as per tables Table 5. Recommended initial standard
the tradition of standard individual angiographic
4a–f (available online at www.bjcardio.co.uk). set of views9
images means that rotational angiography has
Further techniques failed to become widely used. In addition, some Views
operators may find it more convenient to view
In addition to the common practice illustrated Left-sided coronary RAO 30–Cranial 30

and process images individually during the arteries LAO 60–Cranial 30
above, there are two other techniques that are
angiogram and then decide on further views RAO 30–Caudal 30
sometimes used in coronary angiography. The LAO 60–Caudal 30
required, rather than having to process the
Copyright Medinews
first of these is biplane angiography, which
information from a rotational acquisition in one Right coronary artery LAO 40
uses biplane X-ray equipment (essentially like LAO 20–Cranial 20
go. RAO 30
two combined ‘C-arms’) to take simultaneous
orthogonal images. This can be especially useful Finally, as mentioned above, the limitations of Key: LAO = left anterior oblique; RAO = right anterior
oblique
for complex coronary anatomy and for assessing two-dimensional angiography in fully describing
chronic total occlusions (CTOs) and stent position coronary lesions make the possible development
during coronary intervention. In addition, as two of new three-dimensional imaging techniques an
images are acquired per injection of contrast exciting area. Key messages
media there is a potential for less contrast
media use, making it attractive in patients with Conclusion • Knowledge of catheter lab
equipment and coronary anatomy is
renal failure. It is also, therefore, useful in left Learning invasive diagnostic coronary vital to obtaining optimal diagnostic
ventricular angiography. However, it requires angiography is one of the core skills any coronary angiogram images, while
a radiographer/operator skilled in the use and cardiology trainee/fellow must acquire early limiting radiation exposure and
setting up of biplane equipment and accurate contrast load to the patient
in his/her training programme. Knowing and
isocentering of the patient, and one study has
understanding the different angiographic
found that its use in angioplasty can actually
projections is an essential component of
• Breaking the coronary vasculature
result in longer procedure times and increased down into segments when
achieving this goal. Here, we present an performing angiography helps to
radiation exposure, with no significant difference
overview of the radiological equipment used in ensure that coronary stenoses are
in contrast media use.10
angiography, details of the different projections not missed
The second technique is rotational (or ‘spin’) and explain how to optimise images obtained
angiography, in which the ‘C-arm’ is rotated during diagnostic coronary angiography. By • Optimal imaging of each segment
around the patient over the course of a single depends on the use of the correct
simplifying the coronary vasculature into three
angiographic views
Copyright Medinews
contrast media injection. Rotations can be key segments and detailing those projections
linear (e.g. straight LAO to RAO) or elliptical that are commonly used to obtain complete
encompassing LAO and RAO projections with visualisation of each one, we hope to provide
varying degrees of cranial and caudal angulation.
•
an invaluable guide to trainees when they are
The techniques rely on accurate isocentering starting out in the catheter laboratory
of the patient, stable catheter positions, and
consistent injections for the duration of the ‘spin’. Conflict of interest
Again, this results in less contrast media use None declared.
References
1. Joint Royal Colleges of Physicians
Training Board. Specialty Training
Curriculum for Cardiology August
2010. London: JRCPTB, 2010.
Health England, 4 September 2008.
Available from: https://www.gov.uk/
government/publications/medical-
radiation-patient-doses/patient-dose-
information-guidance
4. Einstein AJ, Moser KW,
radiation doses in interventional
cardiology procedures. Curr Cardiol
Rev 2009;5:1–11. http://dx.doi.
org/10.2174/157340309787048059
6. Sianos G, Morel MA, Kappetein
AP et al. The SYNTAX score: an
Cardiovascular Medicine: The PCR-
EAPCI Textbook. PCR Publishing,
2012. ISBN: 9782913628571.
9. Naber CK, Schmitz T, Meuter K,
Sabin GV. Tools and techniques:
angiographic views. EuroIntervention
Available from: https://www.jrcptb.
Thompson RC, Cerqueira MD, angiographic tool grading the 2010;6:424–5. http://dx.doi.
org.uk/sites/default/files/2010%20
Henzlova MJ. Contemporary complexity of coronary artery disease. org/10.4244/EIJV6I3A70
Cardiology.pdf
reviews in cardiovascular medicine: EuroIntervention 2005;1:219–27. 10. Sadick V, Reed W, Collins L,
2. Mauro Moscucci. Grossman and radiation dose to patients from
7. Lanzer P, Topol EJ. Pan Vascular Sadick N, Heard R, Robinson J.
Baim’s Cardiac Catheterization, cardiac diagnostic imaging.
Medicine: Integrated Clinical Impact of biplane versus single-
Angiography, and Intervention. 8th Circulation 2007;116:1290–305.
Management. Springer-Verlag, 2002. plane imaging on radiation dose,
edition. Lippincott Williams and http://dx.doi.org/10.1161/
ISBN: 978-3-642-56225-9. contrast load and procedural time
Wilkins, 2014. ISBN: 1451127405. CIRCULATIONAHA.107.688101
in coronary angioplasty. Br J Radiol
3. Public Health England. Patient dose 5. Pantos I, Patakoukas G, Katritsis 8. Eeckhout E, Serruys PW, Wijns 2010;83:379–94. http://dx.doi.
information: guidance. London: Public DG, Efstathopoulos E. Patient W et al. Percutaneous Interventional org/10.1259/bjr/21696839

INTERVENTION
Table 4a. Common angiographic projections for left main stem8
Segment Main views Examples

Ostial
Copyright Medinews
Shaft
Key: AM = acute marginal; AVC = atrioventricular circumflex; D1 = first diagonal; LAD = left anterior descending; LAO = left anterior oblique;
LCx = left circumflex; LIMA = left internal mammary artery; LMS = left main stem; OM1 = first obtuse marginal; PA = postero-anterior;
PDA = posterior descending artery; PL = posterolateral branch; RCA = right coronary artery; RAO = right anterior oblique; SN = sinus node branch;
VG = vein graft
Table 4b. Common angiographic projections for left anterior descending8
Proximal
Copyright Medinews
(Alternative: PA-Caudal)
Mid
Distal
Key: AM = acute marginal; AVC = atrioventricular circumflex; D1 = first diagonal; LAD = left anterior descending; LAO = left anterior oblique; LCx
= left circumflex; LIMA = left internal mammary artery; LMS = left main stem; OM1 = first obtuse marginal; PA = postero-anterior; PDA = posterior
descending artery; PL = posterolateral branch; RCA = right coronary artery; RAO = right anterior oblique; SN = sinus node branch; VG = vein graft

INTERVENTION
Table 4c. Common angiographic projections for left circumflex8
Proximal
Copyright Medinews (Alternative: PA-Caudal)
Mid
Distal
(Alternative: Straight LAO)
(Alternative:
RAO 10-Caudal 10)
Copyright Medinews
VG = vein graft

INTERVENTION
Table 4d. Common angiographic projections for right coronary artery8
Proximal

Mid Copyright Medinews
Distal
VG = vein graft
Copyright Medinews

INTERVENTION
Table 4e. Common angiographic projections for bifurcation8
LMS and
LAD/LCx
Copyright Medinews
LAD/D1
PL/PDA
OM1/AVC
Copyright Medinews
VG = vein graft

INTERVENTION
Table 4f. Common angiographic projections for graft insertion points8
LIMA to LAD

Copyright Medinews
VG to PDA
VG to OM1
Left RAO 30
ventriculogram
Ascending LAO 40
aortogram
Copyright Medinews
VG = vein graft

Angiographic Views For Coronary Angiography

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Angiographic Views For Coronary Angiography

Uploaded by

Copyright:

Available Formats

Copyright Medinews (Cardiology) Limited Reproduction Prohibited

Optimal angiographic views for

Copyright Medinews (Cardiology) Limited Reproduction Prohibited

Volume 23 Issue 3 | July–September 2016 | The British Journal of Cardiology | 1

Procedure Typical effective doses Vessel Definition

Chest X-ray3 0.02 Overlapping Vessels overlying each other

CT coronary 4–21.4 Plaque Non-concentric plaque,

Excursion Movement of vessels during

2 | The British Journal of Cardiology | July–September 2016 | Volume 23 Issue 3

Collimation and Collimation (or narrowing down)

Copyright Medinews (Cardiology) Limited Reproduction Prohibited

Increased frame Increasing the number of frames

Breath holding Stabilises image and limits

Increased Increased flow rates can improve

Vasodilator use Coronary dilatation can help

Optimising heart Use of verapamil/beta blockers

Co-axial Choosing the correct catheter

Volume 23 Issue 3 | July–September 2016 | The British Journal of Cardiology | 3

In addition to the common practice illustrated Left-sided coronary RAO 30–Cranial 30

4 | The British Journal of Cardiology | July–September 2016 | Volume 23 Issue 3

Table 4a. Common angiographic projections for left main stem8

Segment Main views Examples

Copyright Medinews (Cardiology) Limited Reproduction Prohibited

Table 4b. Common angiographic projections for left anterior descending8

Segment Main views Examples

Volume 23 Issue 3 | July–September 2016 | The British Journal of Cardiology | 5

Table 4c. Common angiographic projections for left circumflex8

Segment Main views Examples

Copyright Medinews (Alternative: PA-Caudal)

6 | The British Journal of Cardiology | July–September 2016 | Volume 23 Issue 3

Table 4d. Common angiographic projections for right coronary artery8

Segment Main views Examples

Copyright Medinews (Cardiology) Limited Reproduction Prohibited

Volume 23 Issue 3 | July–September 2016 | The British Journal of Cardiology | 7

Table 4e. Common angiographic projections for bifurcation8

Segment Main views Examples

8 | The British Journal of Cardiology | July–September 2016 | Volume 23 Issue 3

Table 4f. Common angiographic projections for graft insertion points8

Segment Main views Examples

Copyright Medinews (Cardiology) Limited Reproduction Prohibited

Volume 23 Issue 3 | July–September 2016 | The British Journal of Cardiology | 9

You might also like