Association of PAs in Cardiothoracic and

Vascular Surgery Annual Meeting

April, 7 2018

Stephanie C. Mayberg, MS, PA-C

Service Line Clinical Coordinator
Divsision of Cardiac Surgery
None
• Understand standard views obtained
in diagnostic coronary angiography
• Describe angiographic features
amenable to surgical
revascularization
• Review surgical decision making in
target selection for revascularization
• “Great Consult”
• 82 year old female
• PMHx - CHF, COPD, PAD, A-Fib, CVA,
etc...
• "Great Targets"
• Surgical Planning
• Conduit Selection
• Multiple arterial grafts
• Target-conduit mismatch
• Surgical Approach
• Off Pump
• Hybrid PCI
• X-Ray source
• Located under the table in all cath labs
• Image intensifier (camera)
• Rotation
• Describes location of image intensifier
relative to long axis of patient
• Angulation
• Describes location of image intensifier
relative to short axis of patient
 Angulation

Image
Intensifier

Rotation
• Anterior-Posterior (AP) position- Image intensifier is directly over
the patient with X-Ray beam traveling posterior to anterior. Spine
is in the center of the image
• Left Anterior Oblique (LAO) position - Image intensifier is on
patient left side with X-Ray beam traveling right to left. Spine is
on the right side of the image
• Right Anterior Oblique (RAO) position - Image intensifier is on
patient left side with X-Ray beam traveling left to right. Spine is on
the left of the image
• Cranial Angulation - Image intensifier is angled towards patient
head. Presence of diaphragm often noted
• Caudal Angulation - Image intensifier is angled toward patient
feet.
 LAO Views
◦ Ribs point down to the left
◦ Foreshortening of the LV Apex – Heart appears
round
 RAO Views
◦ Ribs point down to the right
◦ Heart is on the right
◦ Apex points right
 Latin “Corona”
 Greek ”Koron”
 True anatomic definition Artery which gives
supply to the AV Node
 More commonly defined as artery supplying
posterior descending artery
 If RCA supplies PDA – Right Dominant (70%)
 If LCx supplies PDA – Left Dominant (10%)
 PDA supplied by both RCA and LCx – “Co-
Dominant” (20%)
 Arises from the left
coronary cusp
 Divides into left
anterior descending
and left circumflex
 Occasionally 3rd
branch – Ramus
branch
 Best seen in “Spider
View” – LAO Caudal
 LAO Cranial
 Provides blood supply
to anterior wall of left
ventricle
 Septal branches supply
interventricular septum
 Diagonal branch to
anterior lateral wall
 “3-Ls” LAO-LAD-LEFT
 LAO Cranial – LM,
Proximal and Mid LAD
 RAO Caudal – proximal
LAD
 RAO Cranial – Mid LAD,
Distal LAD
 Courses around laterally into
left AV groove
 Gives rise to obtuse marginal
branches
◦ Numbered sequentially
 Gives rise to atrial branches in
AV Groove
 Proximal LCx
◦ RAO Cranial, LAO Caudal
 Obtuse Marginal
◦ RAO Caudal, RAO Cranial, LAO
Caudal
 Arises from right
coronary cusp and
follows right AV
groove
 Supplies RVOT and
SA node
 Often gives rise to
posterior
descending artery
 LAO Cranial
 ”Four Corners”
◦ LAO Cranial
 LAD and Diag
◦ LAO Caudal
 Proximal LAD, Proximal LCx, Distal LM
◦ RAO Caudal
 LM, Proximal, Mid, Distal LCx
◦ RAO Cranial
 Proximal, Mid LAD
 2 Views
◦ LAO Cranial – Proximal and mid RCA
 RCA looks like the letter C
◦ RAO Cranial – Proxmial and Mid RCA
 RCA looks like the letter L
 Supplemental Views
◦ AP Cranial – Distal RCA
 AP View – Shows LIMA in relation to midline
 Lateral View – Shows LIMA in relation to
sternum
◆ LAO-Caudal view: 400 to 600 LAO and 100 to 300 caudal
◆ Best for visualizing left main, proximal LAD and proximal LCx
◆ RAO-Caudal view: 100 to 200 RAO and 150 to 200 caudal
◆ Best for visualizing left main bifurcation, proximal LAD and the
proximal to mid LCx
◆ Shallow RAO-Cranial view: 00 to 100 RAO and 250 to 400 cranial
◆ Best for visualizing mid and distal LAD and the distal LCx (LPDA
and LPL)
◆ Separates out the septals from the diagonals
◆ LAO-Cranial view: 300 to 600 LAO and 150 to 300 cranial
◆ Best for visualizing mid and distal LAD, and the distal LCx in a left
dominant system
◆ Separates out the septals from the diagonals
• Always approach images in same order
• Use contextual clues
• Catheter size
• 1 French = 0.33 or 1/3 mm
• 3 French = 1 mm
• 6 French = 2 mm
• 7 French = 2.33 mm
• 8 French = 2.66 mm
• 9 French = 3 mm
• 10 French = 3.3 mm
• Delayed/slow filling vessels
• Straight appearing vessels usually intramyocardial
• Retrograde filling
• Calcium
◆ Evaluationof the extent and severity of
coronary calcification just prior to or soon after
contrast opacification
◆ Lesion quantification in at least 2 orthogonal
views:
◆ Severity

◆ Calcification

◆ Presence of ulceration/thrombus
◆ Degree of tortuosity
◆ Reference vessel size
◆ Identifying and quantifying coronary collaterals
◆ TIMI 0 flow: absence of any antegrade flow beyond
a coronary occlusion
◆ TIMI 1 flow: (penetration without perfusion) faint
antegrade coronary flow beyond the occlusion, with
incomplete filling of the distal coronary bed
◆ TIMI 2 flow: (partial reperfusion) delayed or
sluggish antegrade flow with complete filling of the
distal territory
◆ TIMI 3 flow: (complete perfusion) is normal flow
which fills the distal coronary bed completely
◆ Type A Lesion – PCI High Success, Low Risk
◆ Less than 10 mm, discreet, concentric, readily accessible, less than, <45°, no
calcification, no side branch or ostial involvement, no thrombus

◆ Type B Lesion – PCI Moderate Success, Moderate Risk

◆ Moderately complex, tubular (length 10 to 20 mm), eccentric, moderate
tortuosity of proximal segment, moderately angulated segment (>45°, <90°),
irregular contour, moderate or heavy calcification, total occlusions <3 months
old, ostial in location, bifurcation lesions requiring double guidewires, and
some thrombus present

◆ Type C Lesion – PCI Low Success, High Risk

◆ Severely complex, diffuse (length >2 cm), excessive tortuosity of proximal
segment, extremely angulated segments >90°, total occlusions >3 months old
and/or bridging collaterals, inability to protect major side branches, and
degenerated vein grafts with friable lesions.
 Angiographic grading tool to determine
complexity of CAD
 Calculation
◦ Dominance
◦ Lesion Location
◦ Degree of stenosis
◦ Ostial involvement
◦ Lesion length
◦ Vessel tortuosity
◦ Vessel calcification
 Scores indicate outcomes of 3 vessel PCI, with
high scores = high risk
 Syntax >22 – CABG offers survival benefit
 Guide wire-based procedure that can accurately
measure blood pressure and flow through a
specific part of the coronary artery
 Used to determine hemodynamic significance of
indeterminate lesions
◦ Patient hasn't experienced symptoms, like angina or
chest pain.
◦ Lesion can be seen clearly on the monitor in the cath lab.
◦ The cardiologist may be tempted to stent the lesion -
After all, there's a blockage there - why not take care of
it?
◦ "oculo-stenotic reflex" -- you see a stenosis, so you
open it up and stent it.
 Defined as the pressure distal to a stenosis
relative to the pressure before the stenosis.
 Hemodynamically significant FFR is less than
0.75
 FFR 0.75-0.8 are intermediate
 An FFR of 0.80 means that a given stenosis
causes a 20% drop in vessel pressure.
 FFR takes into account collateral flow, which can
render an anatomical blockage functionally
unimportant.
 Standard angiography can underestimate or
overestimate narrowing due to 2 dimensional
view
 Coronary stenosis is crossed with an FFR-specific guide
wire designed to record the coronary arterial pressure
distal to the stenosis.
 Once the transducer is distal to the stenosis, a hyperemic
stimulus is administered by injection through the guide
catheter, and the FFR is monitored for a significant
change.
 To achieve maximum hyperemia, adenosine is typically
used:
◦ a 15-30 µg bolus in the right coronary artery,
◦ a 20-40 µg bolus in the left coronary artery, or
◦ intravenous (IV) infusion for 3-4 minutes at 140 µg/kg/min.
 The mean arterial pressures from the pressure wire
transducer and from the guide catheter are then used to
calculate FFR.
 FAME Study
◦ Evaluated the role of FFR in patients with multivessel
coronary artery disease.
◦ 20 centers, 1005 patients undergoing PCI
◦ Randomized to intervention based on angiography
 all suspicious-looking lesions were stented
◦ Intervention based on fractional flow reserve in addition to
angiography.
 lesions with an FFR of 0.80 or less were stented.
◦ In the patients whose care was guided by FFR, fewer stents
were used (2.7±1.2 and 1.9±1.3, respectively).
◦ After one year, the primary endpoint of death,
nonfatal myocardial infarction, and
repeat revascularization were lower in the FFR group (13.2%
versus 18.3%)
 Performed with high fidelity pressure wires that are passed
distal to the coronary stenosis.
 The enhancement over FFR obviates the need for
adenosine
 iFR isolates a specific period in diastole known as the
wave-free period.
 During this time, competing forces (waves) that affect
coronary flow are quiescent, and pressure and flow (Pd
and Pa) are linearly related as compared to all other
periods in the cardiac cycle.
 Therefore, when a stenosis is flow limiting, Pd and Pa
pressures over the wave-free period diverge,
 with iFR values below 0.9 suggesting flow restriction
(normal value is 1.0).
 Typically averaged over five beats for normalization.
 iFR >0.93 no intervention is indicated
 iFR less than 0.86 should be treated with
revascularization
 If iFR measurements fall between 0.86 and
0.93, an FFR can be conducted after
administration of adenosine
 Always approach coronary angiography
systematically
 Use anatomical landmarks to orient the view
 Use contextual clues to aid in diagnosis
 Look at as many cath films as you can