Handbook of Advanced Interventional Cardiology - part 2 pptx

48 Practical Handbook of Advanced Interventional Cardiology CAVEAT: Deceiving angiographic views: There are an- giographic views that minimize the severity of an angulated segment or the severity of a lesion. The most common situ- ation is the RAO caudal view for a lesion in the LCX. This view foreshortens the proximal segment of the LCX so the ostial lesion of the LCX can be missed and the lesions in the proximal segment can be overlooked. In the RAO cranial or LAO cranial views, the lesion in the distal LM can also be missed; if there is a problem advancing the device or thrombus formation after manipulation of interventional hardware, then the severity of the lesion is much more ap- preciated. In the LAO cranial view, the lesion in the proximal LAD can be missed, because it is foreshortened and a le- sion there can be seen better in the RAO cranial view or AP cranial view. During PCI of an RCA lesion, the guide is thought to be coaxial in the LAO view; however, after failing to advance the interventional devices or diffi culty in with- drawing them, it is found that the guide is not coaxial in the RAO view (Table 3-7). CAVEAT: Missing lesions: Coronary angiography or “luminography” is well known to miss severe lesions, es- pecially the short, napkin ring lesion or short aorto-ostial lesions. The reason is that when the lesion is viewed from an angled projection, the lesion is not seen because the adjacent contrast-fi lled vessel segments are projected over the short and diseased segment and mask it. In the case of an ostial lesion, the tip of a small catheter can be engaged too deeply without causing ventricularization of blood pres- s u re and s pi l l- over o f co n tra st in t he a o r t o - o s ti a l are a wo ul d m as k a s ho r t , sev er e o st i al le s io n . T hi s i s th e s a me pr o bl e m of PCI in ostial lesion, where it is diffi cult to position the proximal end of the stent because an angiogram will spill contrast over the ostial area (Figure 3-10). Table 3-7 Suboptimal and deceiving angiographic views 1. RAO caudal views for the ostial and proximal LCX. Better view: AP caudal with deep inspiration (or vice versa) 2. LAO view of the proximal or ostial RCA. Better view: LAO caudal to have better delineation of the ostium. RAO view to check coaxial position. 3. LAO view for origin of distal PDA. Better view: LAO cranial or AP cranial view with deep inspiration in order to depress the diaphragm further. 4. AP view of the distal LM. Better view: LAO caudal (spider view) or cranial angulation. 5. LAO cranial view for the proximal LAD. Better view: RAO cranial or AP cranial. Angiographic Views 49 Balloon and stent oversizing: In the RAO caudal view, the size of the tip of the guide is projected smaller than the projected size of the LCX, OM or distal RCA because the LCX, OM, distal RCA is more posterior, so it is more enlarged than the tip of the guide on the image intensifi er. It is the same problem for measuring the size of the distal LAD in the RAO cranial view. In all circumstances, the im- age intensifi er should be as close to the patient’s chest as possible (Table 3-7). CAVEAT: Magnifi cation artifacts: In many patients undergoing PCI in the LCX, the reference size of the mid- segment of the LCX is measured on the RAO caudal view. In this view, the tip of the guide at the LM ostium is more an- terior, while the mid-segment of the LCX is more posterior, at the level of the aorta, so the mid-segment of the LCX (and the shaft of the guide compared with its tip) is projected bigger on the camera screen. This is why the size of LCX as measured by QCA can be quite deceptive (bigger than real l if e ) . T h i s i s t he c au s e o f ba ll o on or s te nt ov er s izi ng i n P CI o f LCX. The same problem happens with mid- and distal seg- ments of all arteries (Table 3-8) (Figure 3-11 A–D). Radiation exposure to the operators: The operator should be cautious in using the views in order to protect him- self or herself and the staff against radiation exposure. Figure 3-10: During angiogram of the ostial RCA, spill-over of contrast may mask the exact location of the ostium and its abnormality. 50 Practical Handbook of Advanced Interventional Cardiology Table 3-8 Best views for balloon or stent sizing Left anterior descending artery Segment Best view Proximal or mid-LAD RAO or left lateral Distal LAD RAO cranial (caution for magnifi ca- tion artifact) Left circumfl ex artery Segment Best view Proximal LCX RAO caudal and LAO Distal LCX or OM RAO caudal (caution for magnifi - cation artifact) Right coronary artery Segment Best view Proximal, mid-RCA RAO, LAO, left lateral Distal RCA, PDA, PLB AP, LAO cranial (caution for magni- fi cation artifact) Figure 3-11: False magnifi cation of the LCX. (A) With the size of the guide tip as reference, the OM was measured as 3.8 mm proximally to the lesion and 3.3 mm distally to the lesion, so a 3.25-mm balloon was selected for predilation. (Continued) A Angiographic Views 51 TECHNICAL TIPS **Angulations that cause the most radiation exposure to the operators: The steep LAO cranial angulation is the view that results in the most radiation exposure. It is due to redirection of scatter radiation toward the operator, and the increased scatter produced by the higher kVp level re- quired for hemiaxial angulation. 9 Figure 3-11: (B) During infl ation, an angiogram showed total occlusion of the artery, so the balloon fi tted well. The body of the guide looked bigger than the tip. (C) Then a 3.0-mm stent was selected and deployed. The angiogram also showed the same size for the proximal segment and the stent. (Contin- ued) C B 52 Practical Handbook of Advanced Interventional Cardiology **Angiographic views and avoidance of radiation over- exposure in obese patients: In order to permit adequate XR penetration, avoid deep angulation, especially caudal angulation. The image magnifi cation is also lower, to re- duce patient and operator radiation exposure and limit the amplitude of table panning, thus reducing motion artifacts. In selected suspicious areas, the areas will be re-imaged with higher magnifi cations. 9 CORONARY ARTERY ANOMALIES The most common anomaly is the variation of coronary artery origin from the aorta. Usually, they are of no clinical signifi cance, except in the case of origin of the LM from the right sinus or the RCA from the left sinus that is compressed, resulting in ischemia and sudden death. 10–11 When the LCX originates from the RCA or right sinus, usually it takes the retroaortic course to supply the lateral wall of the ventricle and is benign. The left or right coronary artery can originate from the posterior sinus (very rare) or from the ascending aorta like a bypass graft. 12 Besides an ectopic origin, their anatomic course is usually normal. These anomalies are considered benign. Figure 3-11: (D) The post-stenting angiogram showed there was no discrepancy between the diameter of lumen in the stented area and its proximal segment. The real diameter of the artery was around 3.0 mm, not 3.8 mm, as measured with the tip of the guide as reference. D Angiographic Views 53 When the LCA or RCA originate from the opposite sinus, there are four pathways. The rare form is the interarterial course and the most common is the septal course. The other two forms are the retroaortic and the anterior courses. The interarterial course is the most serious one because it can cause ischemia, leading to sudden death. TECHNICAL TIPS **The dots and the eyes: The course of an anomalous coronary artery is confi rmed by the fi lming of the pathway in the 30° RAO view. In this visualization, a dot represent- ing the artery seen end-on is noted. The most severe one, the interarterial pathway of an anomalous LM crossing between the aorta and the pulmonary artery, is recognized by the position of the “dot” anterior to the aorta. If the “dot” is behind the aorta, this is the retroaortic benign pathway. 13 The septal pathway is recognized by the fi sh-hook picture in the RAO view, because the LM goes down to the septum, then comes up to the epicardium, making a picture of a fi sh-hook. Then the LCX would curve backward and form the “eye”, with the LCX as the upper border. 13 In the anterior (pathway) the LM is in front of the pulmonary artery. This pathway is recognized by the “eye”, with the LM as the up- per border and the LCX as the inferior border (Figure 3-12). **How to identify and locate the dots and the eyes: In the 30° RAO view, a selective coronary angiogram can show clearly a dot as the artery is fi lmed end-on. This dot is con- sidered behind the aorta if, during the left ventriculogram, the dot is seen again when the late fl ow opacifi es the aorta and barely both coronary arteries. This ventriculogram locates the dot in front (interarterial pathway) or behind the aorta (retroaortic pathway). The most practical way is to fi lm the coronary artery in the 30° RAO view to show the dot and to do the left ventriculogram with the same angulation. Then the dot can be identifi ed by superimposing (mentally) these two pictures. Another way (for academic purposes) to locate the dot is to do a root aortogram to locate exactly the aorta and the dot. **How to locate the pathways: In order to clarify the posi- tion of an anomalous LM branch in respect of the aorta and pulmonary artery, it may be useful to insert a pulmonary artery (Swan-Ganz) catheter in the main pulmonary artery and to perform a coronary angiogram in the 90° lateral and in the 45° LAO projections. Angiographically, in case of interarterial course, the anomalous LM crosses the pulmo- nar y arter y catheter with an almost linear posterior course. If the anomalous vessel is anterior to the pulmonary artery, it crosses the main pulmonary catheter with a circular 54 Practical Handbook of Advanced Interventional Cardiology Figure 3-12: General view of coronary anomalies. (Adapted f r o m S e r o t a H , B a r t h I I I C W, S e u c C A et al. Rapid identifi cation of the course of anomalous coronary arteries in adults: The “dot and eye” method. Am J Cardiol 1990; 65: 891–8.) Angiographic Views 55 anterior course forming the base of a virtual eye. Moreover, in the 45° LAO projection, the presence of a septal branch arising directly from the left main with a parallel course to the pulmonary catheter excludes the interarterial course and identifi es the septal type. Another way to locate the anomalous LM (right to left) or the anomalous RCA (left to right) pathway is to insert into the LM or the anomalous RCA only the opaque tip of an angioplasty wire (30 mm long), with the pulmonary artery catheter across the main pulmo- nary artery. First it is fi lmed on a plain AP view to see where these two wire-catheters are crossing each other. Then it is fi lmed on the 45° LAO or LAO caudal view to see whether the fi rst part of the LM is in front or behind the pulmonary ar ter y cathet er. I f it is i n front, t hen it i s t he ante r i or pathway. If it is behind the pulmonary artery, then it is the interarterial pathway. If it is far behind, around the aorta, then it is the retroaortic pathway. In 2003, the best way to defi nitively identify an anomalous pathway is to do a fast CT scan or MRA. The pathway can be imaged clearly in a static view. ANGIOGRAPHIC VIEWS The single coronary artery The single coronary artery (SCA), defi ned as an artery that arises from an arterial trunk and nourishes the entire myo- cardium, is rare. This anomaly, divided into two types, right a n d l e f t s i n g l e c o r o n ar y a r t e r y, c a n b e c l a s s i fi e d i n f o ur d i s t i n c t subtypes depending on the course of the major branch: “ante- rior” to the pulmonary artery, “posterior” to the aorta, between the aorta and pulmonary artery (“interarterial”), and “septal”. The prognosis depends on the pathways as in any anomalous major branch crossing from left to right or vice versa (Figure 3-13). The left circumfl ex artery from the right sinus The most common coronary anomaly is the LCX arising from the proximal RCA. This variant is benign. When the LCX arises from the right coronary cusp or the proximal RCA, it invariably follows a retroactive course, with the LCX passing posteriorly around the aortic root to its normal location. On the LAO, the LCX is seen originated from the proximal RCA. On the selective left coronary angiography, the LM looks surpris- ingly long and the LAD is seen large without an LCX. In a 30° RAO view, the LCX will be seen curving in the posterior area and is seen head-on, as a dot, posterior to the aorta. 13 When the LCX originates from the proximal RCA, near the ostium, if the catheter tip is engaged too deeply, it can pass the ostium of the anomalous LCX and miss opacifying the LCX (Figure 3-14). 56 Practical Handbook of Advanced Interventional Cardiology The right coronary anomalies Anterior position of the ostium: If the origin of the RCA is minimally displaced anteriorly, at that time, the tip of the right Judkins catheter may not be directed to the right, but rather looks foreshortened in the familiar LAO view. Directing the tip to the right in the usual fashion using the LAO view permits easy cannulation of the anteriorly directed RCA orifi ce. 14 In the RAO view, there would be an angle between the catheter tip and the ostium, with the tip pointing toward the left (see Figure 3-8 B). Anomalous origin of the RCA from the left sinus: When the RCA arises from the left sinus or from the proximal LM, in the RAO view, the RCA will be seen head-on, as a dot anterior to the aorta. 13 The patient in Figure 3-15 is a middle- aged nurse with acute myocardial infarction (AMI). Two years later her son had an angiogram that showed exactly the same anomaly (Figure 3-15). The left main coronary artery anomalies The incidence of LMCA originating from the right sinus is very low (1.3%). 15 The artery, seen in the RAO view, may Figure 3-13: The single coronary artery originated from the right sinus. In this RAO view, the left main forms the base of the eye and the LAD curves above it forming the upper part of the eye. The left main had a septal pathway. (Courtesy of the Catheterization Laboratories, Department of Specialistic Medicine, Division of Cardiology, Legnago Teaching Hospital, Verona, Italy.) Angiographic Views 57 course in front of the pulmonary artery (anterior course), through the septum (septal course), between the aorta and the pulmonary artery trunk (interarterial course), or behind the aorta (retroaortic course) (see Figure 3-12). Accurate Figure 3-14: In this RAO view, the LCX that is originated from the RCA is seen in a retroaortic pathway as the dot is seen behind the aorta and the artery curves posteriorly. Figure 3-15: In this left coronary injection, an anomalous RCA originated from the left sinus was seen. It was occluded because of AM I. It was the n suc c e ssful ly ope ned. [...]... (eds), Practical Handbook of Advanced Interventional Cardiology, 2nd edn © 20 03 Futura, an imprint of Blackwell Publishing 63 64 Practical Handbook of Advanced Interventional Cardiology Guide selection and manipulation for RCA lesions **Selection of guides for horizontal takeoff angle **Selection of guides for superiorly oriented takeoff angle **Selection of guides for inferiorly oriented takeoff angle **Avoiding... of the tip similar to the Amplatz guide Figure 4 -2 : Passive Amplatz maneuver The whole distal part of the Judkins left guide is prolapsed into the aortic root with the tip pointing into the LM ostium 76 Practical Handbook of Advanced Interventional Cardiology GUIDE SELECTION AND MANIPULATION FOR RCA LESIONS The RCA usually arises anterolaterally from the right coronary cusp In the large majority of. .. **Selecting the size of Judkins guide *Engagement of a Judkins left guide **Non-coaxial position of a small Judkins guide *Guide that is too large *Guide that is too small *Engagement of a Judkins right guide Maneuvering an Amplatz guide **Selection of an Amplatz guide **Engagement of an Amplatz guide **Optimal position of an Amplatz guide **Withdrawal of an Amplatz guide **Withdrawal of an Amplatz guide... trunk Because of the low pulmonary resistance, 60 Practical Handbook of Advanced Interventional Cardiology the fully oxygenated blood arriving in the anomalous coronary artery, via collaterals from the normal coronary artery, is stolen by the pulmonary trunk, resulting in myocardial ischemia The treatment includes surgical ligation of the RCA and bypass or re-implantation of the RCA .21 REFERENCES 1... Angioplasty McGraw-Hill, 1985: 27 4–87 2 Boucher RA Coronary angiography and angioplasty Cathet Cardiovasc Diagn 1986; 14: 26 9–85 3 King III SB, Douglas JS Percutaneous transluminal coronary angioplasty In: King SB, Douglas JS, eds Coronary Arteriography and Angioplasty McGraw-Hill, 1985: 443 4 Vetrovec G Cardiac catheterization and interventional cardiology self-assessment program American College of Cardiology, ... should be pushed deep in the left sinus of Valsalva, causing it to make an anterior and cephalad pointing U-turn The larger curve will prevent the guide from engaging the patient’s LM (see Figure 3-1 5) .24 By the same principle, an AL -2 with a tip pointed more anteriorly, would help to cannulate the artery .20 Others reported the use of a JL-4 with an eccentric tip FL4-G (USCI) to cannulate the anomalous... eccentric tip FL4-G (USCI) to cannulate the anomalous RCA from the left sinus The primary curve of the type G catheter is out of plane 82 Practical Handbook of Advanced Interventional Cardiology to the remainder of the catheter in an anterior orientation, therefore avoiding the normal left coronary ostium .25 **Guides for right coronary artery with anomalous origin: This artery usually arises from an... superiorly toward and engage the LM ostium **Non-coaxial position of a small Judkins guide: If a small Judkins guide is chosen, with its tip not coaxial to the LM, that tip will point superiorly to the wall In that position, 70 Practical Handbook of Advanced Interventional Cardiology even though there is no dampening of aortic pressure, an injection of contrast agent in young patients may not cause... starting from the posterior sinus or noncoronary cusp in the 30° RAO position The guide is 72 Practical Handbook of Advanced Interventional Cardiology advanced with the tip pointed toward the spine When a loop is formed, slight clockwise rotation flips the tip of the left cusp and points it toward the ostium The tip is then advanced or withdrawn slightly to cannulate the LM ostium The RCA is approached in the... (Figure 3-1 ) **Dampening pressure: Dampening of the aortic pressure can be due to an LM lesion and, in rare cases, due to a mismatch between the large-size guide and a small coronary ostium Gradual repositioning and withdrawal of the guide may eliminate pressure dampening. 12 A few senior angiographers suggest a small injection of contrast with quick removal of the tip of the guide (“hit and run”) tech- Guides . exposure. Figure 3-1 0: During angiogram of the ostial RCA, spill-over of contrast may mask the exact location of the ostium and its abnormality. 50 Practical Handbook of Advanced Interventional Cardiology Table. proximal segment and the stent. (Contin- ued) C B 52 Practical Handbook of Advanced Interventional Cardiology **Angiographic views and avoidance of radiation over- exposure in obese patients: In order. Practical Handbook of Advanced Interventional Cardiology, 2nd edn. © 20 03 Futura, an imprint of Blackwell Publishing. Chapter 4 Guides Thach Nguyen, Nguyen Thuong Nghia, Vijay Dave 64 Practical Handbook