Basic Coronary Artery Anatomy

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Paul Fefer, MD.Interventional Cardiology Unit

Sheba Medical Center, Tel Hashomer

Courtesy of Frederick Feit, MD

Paul Fefer, MD.Interventional Cardiology Unit

Sheba Medical Center, Tel Hashomer

Courtesy of Frederick Feit, MD

The Cardiovascular Research FoundationThe Cardiovascular Research Foundation Transcatheter Cardiovascular TherapeuticsTranscatheter Cardiovascular Therapeutics

Medtronic Fellows PCI PrimerMedtronic Fellows PCI Primer

Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy

Sternocostal Aspect

Diaphragmatic Aspect

Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy

77thth Annual Interventional Cardiology Self-Assessment Course at TCT2004 Annual Interventional Cardiology Self-Assessment Course at TCT2004

Basic Coronary Artery AnatomyBasic Coronary Artery Anatomy: Frederick Feit, M.D. : Frederick Feit, M.D.

Right Coronary ArteryRight Coronary Artery

• OriginRight aortic sinus (lower origin than LCA)

• CourseDown 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.

• Supplies25% to 35% of Left Ventricle

• OriginRight aortic sinus (lower origin than LCA)

• CourseDown 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.

• Supplies25% to 35% of Left Ventricle

Basic AnatomyBasic Anatomy

• Conus Arteryusually 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.

• Conus Arteryusually 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.

Other BranchesOther 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.

• 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.

Other BranchesOther Branches

• LAO (30) Cranial(30)particularly for distal bifurcation (AP Cranial may be better).

• RAOmain shaft; cranial enhances distal vessels and very proximal; caudal may help with Shepherd’s crook.

• Lateralbifurcations with RV branches-distal bifurcation, particularly with cranial.

• LAO (30) Cranial(30)particularly for distal bifurcation (AP Cranial may be better).

• RAOmain shaft; cranial enhances distal vessels and very proximal; caudal may help with Shepherd’s crook.

• Lateralbifurcations with RV branches-distal bifurcation, particularly with cranial.

Optimal View(s)Optimal View(s)

LAO Cranial Angiogram of RCALAO Cranial Angiogram of RCA

PDAPDAPDAPDA

Acute MarginalAcute MarginalAcute MarginalAcute Marginal

RAO Angiogram of RCARAO Angiogram of RCA

Native RCA Lateral ViewNative RCA Lateral View

Acute Acute MarginalMarginalAcute Acute MarginalMarginal

Main RCAMain RCAMain RCAMain RCA

Demonstrating Origin of Acute MarginalDemonstrating Origin of Acute Marginal

AP Cranial View of Distal RCAAP Cranial View of Distal RCA

PDAPDAPDAPDA

RPL 1RPL 1RPL 1RPL 1

RPL 2RPL 2RPL 2RPL 2

Left Coronary ArteryLeft Coronary Artery

• Originupper 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 case-other 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 ViewsLAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUS

• Originupper 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 case-other 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 ViewsLAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUS

Left Main Coronary ArteryLeft Main Coronary Artery

Sternocostal Aspect

Diaphragmatic Aspect

Left Anterior Descending ArteryLeft Anterior Descending Artery• Course

down the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apex.

• Branchesseptals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus (courses like 1st diagonal).

• LADSupplies anterolateral, apex and septum; ~45%-55% of left ventricle.

• Coursedown the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apex.

• Branchesseptals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus (courses like 1st diagonal).

• LADSupplies anterolateral, apex and septum; ~45%-55% of left ventricle.

Left Circumflex ArteryLeft Circumflex Artery• Origin

from distal LMCA.• Course

down distal left AV groove.• Branches

obtuse marginal, posterolaterals-supply posterolateral LV, anterolateral papillary muscle. SA node artery-38%.

• Supplies15%-25% of LV, unless dominant (supplies 40-50% of LV).

• Originfrom distal LMCA.

• Coursedown distal left AV groove.

• Branchesobtuse marginal, posterolaterals-supply posterolateral LV, anterolateral papillary muscle. SA node artery-38%.

• Supplies15%-25% of LV, unless dominant (supplies 40-50% of LV).

Left Coronary ArteryLeft Coronary Artery

• AP (30)CaudalLMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO may be useful.

• AP (40)CranialLMCA, LAD, diagonals, septals, distal Cx-may need RAO to separate LAD and Cx.

• (45)LAO (35) CranialLMCA, LAD, diagonals, septals, and distal Cx.

• (45)LAO (30) CaudalLMCA, Cx,and prox LAD.

• Laterals (cranial, caudal)may be helpful.

• AP (30)CaudalLMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO may be useful.

• AP (40)CranialLMCA, LAD, diagonals, septals, distal Cx-may need RAO to separate LAD and Cx.

• (45)LAO (35) CranialLMCA, LAD, diagonals, septals, and distal Cx.

• (45)LAO (30) CaudalLMCA, Cx,and prox LAD.

• Laterals (cranial, caudal)may be helpful.

Optimal ViewsOptimal Views

AP Caudal View of LCAAP Caudal View of LCA

LADLAD

CircCirc

SeptalSeptalSeptalSeptal

LADLADLADLAD

CxCxCxCx

DiagonalDiagonalDiagonalDiagonal

AP Cranial View of LCAAP Cranial View of LCA

AP Cranial LCA AngiogramAP Cranial LCA Angiogram

SeptalSeptalSeptalSeptal DiagonalsDiagonalsDiagonalsDiagonals

LADLADLADLAD

LMCALMCALMCALMCA CxCxCxCx

CircCircCircCirc

DiagonalDiagonalDiagonalDiagonalLADLADLADLAD

LAO Cranial View of LCALAO Cranial View of LCA

LAO Caudal View of LCALAO Caudal View of LCA

CircCircCircCirc

LADLADLADLAD Median RamusMedian RamusMedian RamusMedian Ramus

Dominance: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

• 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

LeftDominant

Circulation

LeftDominant

Circulation

LCA AngiogramLCA Angiogram

Distal LADDistal LADDistal LADDistal LAD

Prox LADProx LADProx LADProx LADLMLMLMLM

OMOMOMOM

Distal CxDistal CxDistal CxDistal Cx

Occluded Median RamusOccluded Median RamusOccluded Median RamusOccluded Median Ramus

Dominant Cx AP CaudalDominant Cx AP Caudal

LCA Angiogram-Dominant Cx LAO-CaudalLCA Angiogram-Dominant Cx LAO-Caudal

Distal LADDistal LADDistal LADDistal LAD

LMLMLMLM

Prox CxProx CxProx CxProx Cx

LPDALPDALPDALPDA

OccludedOccludedMedianMedianRamusRamus

Prox LADProx LADProx LADProx LAD

The Coronary Arteries Are ComplementaryThe Coronary Arteries Are Complementary

• Large PDA Small LAD• Huge Cx (posterolaterals) Small RCA continuation in AV Groove• Etc, etc, etc…..

Wrap Around LADWrap Around LAD

Short LAD/Large RCA with Apical ExtensionShort LAD/Large RCA with Apical Extension

BYPASS GRAFTSBYPASS GRAFTS

• SVGLeft 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.

• IMAdon’t forget to check subclavians.

• SVGLeft 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.

• IMAdon’t forget to check subclavians.

All distal vessels must be accounted for; op notes and old films are extremely helpful.All distal vessels must be accounted for; op notes and old films are extremely helpful.

SVG-OM-LAO CaudalSVG-OM-LAO Caudal

Demonstrating Graft OstiumDemonstrating Graft Ostium

OstiumOstium

SVG-OM 1 AP CaudalSVG-OM 1 AP Caudal

Demonstrating AnastomosisDemonstrating Anastomosis

SVGSVGSVGSVG

LIMA to LADLIMA to LAD

Origin from left subclavian (AP Cranial)Origin from left subclavian (AP Cranial)

LIMA to LADLIMA to LAD

Distal Anastomosis-AP CranialDistal Anastomosis-AP Cranial

LIMALIMALIMALIMA

LADLADLADLAD

Left Subclavian Artery StenosisLeft Subclavian Artery Stenosis

RIMA to RCARIMA to RCA

Occluded Left-sided SVGOccluded Left-sided SVG

Native LCA AP CaudalNative LCA AP Caudal

Stump of original Stump of original SVG to OM 1SVG to OM 1Stump of original Stump of original SVG to OM 1SVG to OM 1

SVG to OMSVG to OM

Lesion 1Lesion 1Lesion 1Lesion 1

SVG to OMSVG to OMSlight change of view to demonstrate

unequivocal severity of lesionSlight change of view to demonstrate

unequivocal severity of lesion

SVG to RCASVG to RCA

Multipurpose Technique -LAOMultipurpose Technique -LAO

SVGSVGSVGSVG

Ulcerated PlaqueUlcerated Plaque

LCA AP CaudalLCA AP Caudal

Severe stenosisSevere stenosisSevere stenosisSevere stenosis

Distal LADDistal LADwith slow flowwith slow flowDistal LADDistal LADwith slow flowwith slow flow

Thrombus In LADThrombus In LAD

Post-NTG-Thrombus has migrated distally but still adherentPost-NTG-Thrombus has migrated distally but still adherent

ThrombusThrombusThrombusThrombus

AP Cranial Thrombus In LADAP Cranial Thrombus In LAD

Embolization of Thrombus During AngiographyEmbolization of Thrombus During Angiography

Calcified Native RCACalcified Native RCA(LAO Cranial)

“Bone Island” Simulating Thrombus(LAO Cranial)

“Bone Island” Simulating Thrombus

Myocardial BridgingMyocardial Bridging

• Almost always LAD

• Occurs in 5-12% of patients

• Usually not hemodynamically significant

• Almost always LAD

• Occurs in 5-12% of patients

• Usually not hemodynamically significant

Intramyocardial SegmentIntramyocardial Segment

Myocardial BridgingMyocardial Bridging

LCA-RAO ProjectionLCA-RAO Projection

LAD DiastoleLAD DiastoleLAD DiastoleLAD Diastole LAD SystoleLAD SystoleLAD SystoleLAD Systole

Coronary Artery FistulaCoronary Artery Fistula

• Origin50% 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%.

• Origin50% 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%.

Coronary Artery FistulaCoronary Artery FistulaLCA-RAO Projection

LAD to PA FistulaLCA-RAO Projection

LAD to PA Fistula

LADLADLADLAD

PAPAPAPA

FistulaFistulaFistulaFistula

Anomalous Origin of LCA from theRight Sinus of Valsalva

• Rare• Course relative to great vessels is variable

and must be defined. If interarterial, surgical therapy is warranted.

• Rare• Course relative to great vessels is variable

and must be defined. If interarterial, surgical therapy is warranted.

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

Normal and Anomalous Origins of the Coronary Arteries

Benign Anomalies (0.5-1%)Benign Anomalies (0.5-1%)

• Left Circumflex from right Sinus of ValsalvaMost common “benign” anomalyCircumflex courses behind aorta

• High Anterior Origin of RCAAbove sinotubular ridge

• Left Circumflex from right Sinus of ValsalvaMost common “benign” anomalyCircumflex courses behind aorta

• High Anterior Origin of RCAAbove sinotubular ridge

Anomalous Circumflex ArteryAnomalous Circumflex Artery

Basic Coronary Artery Anatomy

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