1 Characterize the pulmonary circulation ▪ Identify the origin and course of all MAPCAs ▪ Image the aorta from the root to the proximal abdominal descending segment ▪ Confirm/exclude MAPCAs from head and neck arteries and coronary arteries ▪ Assess relationship of MAPCAs to the major airways ▪ Document the presence/absence of central (mediastinal) pulmonary arteries and which lung segments they supply ▪ Define the source of blood flow to all lung segments ▪ MAPCAs ▪ Central pulmonary arteries ▪ Pulmonary vein wedge angiograms in lobes/segments without evidence of central supply ▪ Document the presence, site, and robustness of connections between MAPCAs and the central pulmonary artery system ▪ Identify stenoses in MAPCAs and pulmonary arteries ▪ Measure pulmonary artery pressures distally (beyond any stenoses) and pressure gradients across any stenosis Document aortic arch sidedness and branching Define origins and proximal epicardial course of the coronary arteries Assess for interventricular pressure gradient (restrictiveness of ventricular septal defect) Confirm/clarify any other anomalies detected or suspected by echocardiography MAPCA, Major aortopulmonary collateral artery; PA, pulmonary atresia; TOF, tetralogy of Fallot FIG 36.12 Angiograms of three major aortopulmonary collateral arteries (MAPCAs) in a patient with tetralogy of Fallot/pulmonary atresia/MAPCAs and Alagille syndrome (A–B) Anteroposterior and lateral images of the same right lung MAPCA; (C–D), separate MAPCAs to the right upper lobe (C, short red arrow), with a connection to the central pulmonary arteries (long red arrow), and the left lower lobe (D) All the vessels are markedly hypoplastic FIG 36.13 Series of selective angiograms from the same patient whose aortogram is depicted in Video 36.2 (A) Left-sided major aortopulmonary collateral artery (MAPCA) divides soon after its origin from the descending aorta Both branches, depicted individually in (B) and (C), are stenotic proximally (asterisks) (B–C) Further selective images of the branches of the collateral in (A) demonstrate stenosis of the segmental branches as well This is an example of a MAPCA that arises from the aorta as a single vessel but requires separate unifocalization of the inferior and superior branches in (B) and (C) (D) The catheter has been advanced to the central pulmonary artery through its connection to a MAPCA in the left lung (note catheter course) and shows a good-sized central pulmonary artery that arborizes to a portion of the right lung (E–F) The remainder of the right lung is supplied by two other collaterals from the descending aorta (E) and the right subclavian artery (F) All of these MAPCAs except (F) are seen on the descending aortogram in Video 36.2