Medtronic Fellows PCI Primer
Basic Coronary Artery
Anatomy
Paul Fefer, MD.
Interventional Cardiology Unit
Sheba Medical Center, Tel Hashomer
Courtesy of Frederick Feit, MD
The Cardiovascular Research Foundation
Transcatheter Cardiovascular Therapeutics
Sternocostal Aspect
Basic Coronary Artery Anatomy
Diaphragmatic Aspect
Basic Coronary Artery Anatomy
Right Coronary Artery
Basic Anatomy
• Origin
Right aortic sinus (lower origin than LCA)
• Course
Down right AV groove toward crux of the heart,
gives off PDA (85%) from which septals arise,
continues in LAV groove giving off posterior LV
branches (posterolaterals). PDA may originate
more proximally, bifurcate early or be small with
part of “its territory” supplied by an acute
marginal branch.
• Supplies
25% to 35% of Left Ventricle
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Right Coronary Artery
Other Branches
• Conus Artery
usually very proximal; (~50% have a separate origin)courses anteriorly and upward over the RV outflow
tract toward the LAD. May be an important source of
collaterals.
• SA Nodal Artery
(~60%) usually 2nd branch of RCA-courses obliquely
backward through upper portion of atrial septum and
anteromedial wall of the RA-supplies SA node, usually
RA and sometimes LA.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Right Coronary Artery
Other Branches
• Right Ventricular (Acute Marginal)
Branches)
Arise from mid RCA; supply anterior
RV; may be a collateral source.
• AV Nodal Artery
Arises at or near crux; supplies AV node.
• PDA
Supplies inferior wall, ventricular
septum, posteromedial papillary muscle.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Right Coronary Artery
Optimal View(s)
• LAO (30) Cranial(30)
particularly for distal bifurcation (AP
Cranial may be better).
• RAO
main shaft; cranial enhances distal vessels
and very proximal; caudal may help with
Shepherd’s crook.
• Lateral
bifurcations with RV branches-distal
bifurcation, particularly with cranial.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LAO Cranial Angiogram of RCA
PDA
Acute Marginal
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
RAO Angiogram of RCA
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Native RCA Lateral View
Demonstrating Origin of Acute Marginal
Main RCA
Acute
Marginal
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
AP Cranial View of Distal RCA
RPL 2
RPL 1
PDA
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Left Coronary Artery
Left Main Coronary Artery
• Origin
upper portion of left aortic sinus just below the
sinotubular ridge. Typically 0-10 mm in length. Rarely
no LM (separate origins).
• Catheterization Technique
“The Judkins’ 4-Left coronary catheter will find the LCA
orifice unless thwarted by the operator”. Just in caseother Judkins sizes for smaller or larger aortas; Amplatz,
XB type curves. Watch for “damping”; For separate
ostia-separate catheters, larger for Cx, or
counterclockwise rotation for LAD.
• Optimal Views
LAO caudal and cranial; AP-caudal, cranial or flat.
Limit views. May need IVUS
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Sternocostal Aspect
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Diaphragmatic Aspect
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Left Anterior Descending Artery
• Course
down the anterior interventricular groove-usually
reaches apex. In 22% of cases does not reach apex.
• Branches
septals and diagonals-supply lateral wall of LV,
anterolateral papillary muscle; 37% have median
ramus (courses like 1st diagonal).
• LAD
Supplies anterolateral, apex and septum; ~45%-55%
of left ventricle.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Left Circumflex Artery
• Origin
from distal LMCA.
• Course
down distal left AV groove.
• Branches
obtuse marginal, posterolaterals-supply posterolateral
LV, anterolateral papillary muscle. SA node artery38%.
• Supplies
15%-25% of LV, unless dominant (supplies 40-50%
of LV).
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Left Coronary Artery
Optimal Views
• AP (30)Caudal
LMCA, proximal LAD, Cx, distal LAD. Poor for mid
LAD- RAO may be useful.
• AP (40)Cranial
LMCA, LAD, diagonals, septals, distal Cx-may need
RAO to separate LAD and Cx.
• (45)LAO (35) Cranial
LMCA, LAD, diagonals, septals, and distal Cx.
• (45)LAO (30) Caudal
LMCA, Cx,and prox LAD.
• Laterals (cranial, caudal)
may be helpful.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
AP Caudal View of LCA
LAD
Circ
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
AP Cranial View of LCA
Cx
LAD
Septal
Diagonal
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
AP Cranial LCA Angiogram
LMCA
Cx
Diagonals
Septal
LAD
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LAO Cranial View of LCA
Circ
LAD
Diagonal
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LAO Caudal View of LCA
LAD
Median Ramus
Circ
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Dominance:
• Definition 1:
the coronary artery which reaches the
crux of the heart and then gives off the
PDA
• Definition 2: (Allows for codominance)
the artery which gives off the PDA as
well as a large posterolateral branch
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Left
Dominant
Circulation
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LCA Angiogram
Dominant Cx AP Caudal
Prox LAD
LM
Occluded Median Ramus
Distal LAD
OM
Distal Cx
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LCA Angiogram-Dominant Cx LAO-Caudal
Prox LAD
Occluded
Median
Ramus
LM
Distal LAD
Prox Cx
LPDA
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
The Coronary Arteries Are Complementary
• Large PDA Small LAD
• Huge Cx (posterolaterals)
 Small RCA continuation in AV
Groove
• Etc, etc, etc…..
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Wrap Around LAD
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Short LAD/Large RCA with Apical Extension
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
BYPASS GRAFTS
• SVG
Left coronary grafts generally arise from
left side of the aorta. Best cannulated with
Judkins’ Right, IMA, LCB or MP.
 Right sided grafts-arise from right side of
the aorta-MP usually best.
• IMA
don’t forget to check subclavians.
All distal vessels must be accounted for; op notes and old films are extremely helpful.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
SVG-OM-LAO Caudal
Demonstrating Graft Ostium
Ostium
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
SVG-OM 1 AP Caudal
Demonstrating Anastomosis
SVG
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LIMA to LAD
Origin from left subclavian (AP Cranial)
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LIMA to LAD
Distal Anastomosis-AP Cranial
LIMA
LAD
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Left Subclavian Artery Stenosis
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
RIMA to RCA
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
RIMA to RCA
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Occluded Left-sided SVG
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Native LCA AP Caudal
Stump of original
SVG to OM 1
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
SVG to OM
Lesion 2
Lesion 1
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
SVG to OM
Slight change of view to demonstrate
unequivocal severity of lesion
Lesion 2
Lesion 1
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
SVG to RCA
Multipurpose Technique -LAO
SVG
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Ulcerated Plaque
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
LCA AP Caudal
Severe stenosis
Distal LAD
with slow flow
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Thrombus In LAD
Post-NTG-Thrombus has migrated distally but still adherent
Thrombus
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
AP Cranial Thrombus In LAD
Thrombus
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Embolization of Thrombus During Angiography
Thrombus
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Calcified Native RCA
(LAO Cranial)
“Bone Island” Simulating Thrombus
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Myocardial Bridging
Intramyocardial Segment
• Almost always LAD
• Occurs in 5-12% of patients
• Usually not hemodynamically significant
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Myocardial Bridging
LCA-RAO Projection
LAD Diastole
LAD Systole
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Coronary Artery Fistula
• Origin50% RCA.
• Clinical Syndromes: CHF, endocarditis,
ischemia, and rupture of aneurysmal fistula.
50% are asymptomatic.
• Drainage: RV-41%; RA-26%; PA-17%;
LV-3%, and SVC-1%.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Coronary Artery Fistula
LCA-RAO Projection
LAD to PA Fistula
PA
Fistula
LAD
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Anomalous Origin of LCA from the
Right Sinus of Valsalva
• Rare
• Course relative to great vessels is variable
and must be defined. If interarterial,
surgical therapy is warranted.
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Anomalous Origin of RCA from Left
Coronary Sinus
•
•
•
•
•
Rare
Arises anterior to the origin of the LCA
Engage with Left Amplatz, or Left Judkins’
RCA runs an interarterial course
Usually benign
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Normal and Anomalous
Origins of the Coronary
Arteries
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Benign Anomalies (0.5-1%)
• Left Circumflex from right Sinus of Valsalva
 Most common “benign” anomaly
 Circumflex courses behind aorta
• High Anterior Origin of RCA
 Above sinotubular ridge
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.
Anomalous Circumflex Artery
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.