Coronary Views and Projections:

Tips, Tricks and Interactive Quiz

UUP HARIANTO
2019
 Learning Objectives
At the end of this module, you will be able to apply specific tips
and tricks to help identify which coronary arteries are being
visualized in which specific view. Specifically:
• At which angle are the ribs?
• Where is the spine?
• Which direction does the guide catheter point?
• Does the vessel have “tendrils”?
• Does the RCA look like a C or an L?
Tips & Trick
At which angle are the ribs ?
In the RAO view, the ribs “mimic” the right hand.

RAO
Ribs mimic right hand
At which angle are the ribs ?
In the LAO view, the ribs “mimic” the left hand.

LAO
Ribs mimic left hand
Where is the spine ?
Using the position of the spine relative to the heart, the right or left viewing angle can be identified

• RAO for the left & right coronary system

– Spine is on the left side of the image

• LAO for the left & right coronary system

– Spine is on the right side of the image
Where is the spine ?
The spine is on the right side of the image indicating an LAO view of the RCA

Spine on the right

LAO view
 Which direction does the guide catheter point?
To help determine which arteries are being visualized, look at the position of the guide catheter

RIGHT Coronary System LEFT Coronary System

(either RAO and LAO view) (either RAO and LAO view)

Guide catheter points Guide catheter points

toward the patient’s toward the patient’s
RIGHT LEFT
Which direction does the guide catheter point ?
The guide catheter is pointing to the patient’s left side, which means the left coronary system is cannulated

Toward the patient’s left

Left Coronary System

Which direction does the guide catheter point ?
The guide catheter is pointing to the patient’s left side, which means the left coronary system is cannulated

Toward the patient’s right

Right Coronary System

Does the vessel have “trendrils” ?
To distinguish which vessel is the LAD, look for the septal perforators (like tendrils or teeth of a comb)
and for the vessel that heads towards the apex of the heart.

• In RAO view, the LAD courses horizontally

RAO of the left coronary system
across the top of the heart, while the LCX
courses perpendicular to the LAD.
LAD • The LAD and diagonals may overlap in this
view.
LCX
Tendrils

Septal perforators
Does the vessel have “trendrils” ?
In the LAO view, the LAD courses far left, the diagonal down the middle,
and the LCX travels across top right, then down. .

LAO of the left coronary system

LCX

LAD
Tendrils
Diag

Septal branches
Does the RCA resemble a “C” or “L” ?
In the LAO view, the RCA resembles a capital “C”

LAO of the left coronary system

LCX

LAD

Diag
Does the RCA resemble a “C” or “L” ?
In the RAO view, the RCA resembles a capital “L” .
The PDA travels away from you in the RAO view

RAO
RCA resembles “L”
Coronary Angiography : Causes for Misinterpretation
Misinterpretation of angiograms can be due to injection- and catheter-related factors

Factors due to injection

• Laminar flow, incomplete Factors due to catheter
opacification • Catheter too small
• Semi-selective injection, compared to the artery
low amount of contrast ostium
agent • Coronary spasm
• Diluted contrast agent induced by positioning
• Fleeting injection the catheter tip
Coronary Angiography : Causes for Misinterpretation
Angiograms can also be misinterpreted because of various view- and anatomy-related factors

Factors due to angio view

• Shortened lesion (non Factors due to coronary
perpendicular view) anatomy
• Superimposition with other • Very tortuous vessel
vessel, catheter or bone • Very short stenosis
structure (diaphragmatic)
• Inadequate choice of angio • Eccentric or concave
views stenosis
 Angiographic Pitfalls: Separate Origins
Separate origin of LAD and LCX is a common variation .

Where is the LCX? Below the LAD

Angiographic Pitfalls: Inadequate View of Distal LM
Single view may not adequately represent the true extent of a lesion – multiple views are recommended.
No obvious stenosis Same patient; severe distal LM stenosis
LAO 45o – cranial 25 RAO 10°– cranial 40°

Severe distal LM stenosis

Angiographic Pitfalls: Inadequate View of Prox LAD
Single view may not adequately represent the true extent of a lesion – multiple views are recommended.
Protected distal LM < 50% proliferation intrastent
Previously treated by stenting LM – LCX but severe prox LAD lesion
RAO 30o RAO 30°– caudal 25°

Severe prox
LAD lesion

Intrastent <50%
Coronary Views and Projections Quiz
Find the right names, views and lesion(s):
• Case 1
• Case 2
• Case 3
Case n° 1 ?
Q: Which artery?
A: LCA (catheter points to the patient’s left)

Q: Which view?
A: RAO 30°(based on orientation of ribs and
spine)

Q: Where are LAD, septal, diagonal, LCX?

A: S1 (look for tendrils) spine

Q: Where is the lesion, how to improve the

view?
A: Arrow, next slide
Case n° 1
Q: Which view and why?
A: 0 - 40° cranial, it is the ideal view
for mid LAD with the septal
branches to the left and the
diagonal branches to the right;
mid LAD is spread out (X-ray
perpendicular to the artery
segment) and the lesion clearly
delineated, i.e. tandem stenosis
(arrows)
Case n° 1
Q: Which artery?
A: LCA (catheter points to the patient’s left)

Q: Which view?
A: LAO 45–25° cranial (spine is on the right)

Q: LAD or LCX?
A: LCX courses toward the spine

Q: This is the same patient as the previous

one – where is the lesion?
A: Arrows, this view was unnecessary
Case n° 1
Q: Which view?
A: LAO 90°

Q: Knowing 4 views now, describe the

lesion and select devices to fix the
problem
A: Type 2b, 80%; EBU 5fr (radial);
floppy wire; stenting 3.5/20 mm
Case n° 1
Q: After stenting, is it a perfect
result?
A: No, 20% residual stenosis
(arrow), but satisfactory
Coronary Views and Projections Quiz
Find the right names, views and lesion(s):
• Case 1
• Case 2
• Case 3
Case n° 2
Q: Which view for which artery?
A: RAO 30-25° caudal, good definition
of LM, prox LAD, prox LCX and OM

Q: Is it a good view for ramus

intermedius, septal and diagonal
branches?
A: No, because of super-imposition of
proximal lateral branches on LAD
(arrows), we need other views

This view at least shows severe mid

LAD stenosis
Case n° 2
Q: Which view?
A: LAO 45-25° cranial

Q: Where is the lesion located? LAD

or D2?
A: This view at least shows a severe
ostial diagonal stenosis, in fact,
both arteries are stenosed

Q: What are the shape and size of

this catheter?
A: EBU4 7Fr, femoral approach
(recommended for bifurcation
procedure)
Coronary Views and Projections Quiz
Find the right names, views and lesion(s):
• Case 1
• Case 2
• Case 3
Case n° 3
Q: Which view for which artery?
A: Catheter points toward
patient’s right = RCA, spine is on
the right side of the frame and
sternum to the left = LAO (90°)
Spine
Q: Describe the lesion
A: Complete occlusion (CTO) of
mid RCA (TIMI 1)
Case n° 3
Q: Which view for which artery?
A: Catheter points toward
patient’s left = LCA; spine is on
the left side of the frame = RAO;
LCX is on the same side as the
spine
Spine
Q: Describe the lesion
A: Long occlusion of the LCX, TIMI
1
Summary of Tips and Tricks
• In the RAO view, the ribs “mimic” the right hand.
• In the LAO view, the ribs “mimic” the left hand.
• Using the position of the spine relative to the heart, the right or left viewing angle
can be identified.
• The spine is on the right side of the image indicating an LAO view of the RCA.
• To help determine which arteries are being visualized, look at the position of the
guide catheter.
• The guide catheter is pointing to the patient’s left side, which means the left
coronary system is cannulated.
• The guide catheter is pointing to the patient’s right, which means the right
coronary system is cannulated.
Summary of Tips and Tricks
• To distinguish which vessel is the LAD, look for the septal perforators (like tendrils
or teeth of a comb) and for the vessel that heads towards the apex of the heart.
• In the LAO view, the LAD courses far left, the diagonal down the middle, and the
LCX travels across top right, then down.
• In the LAO view, the RCA resembles a capital “C”.
• In the RAO view, the RCA resembles a capital “L”. The PDA travels away from you in
the RAO view.
• Misinterpretation of angiograms can be due to injection-, catheter-, various view-
and anatomy-related factors.
• Separate origin of LAD and LCX is a common variation.
• Single view may not adequately represent the true extent of a lesion – multiple
views are recommended.