0. Basic Coronary Artery Anatomy
Medtronic Fellows PCI Primer
Basic Coronary Artery Anatomy
Paul Fefer, MD.
Interventional Cardiology Unit
Sheba Medical Center, Tel Hashomer
Courtesy of Frederick Feit, MD
The Cardiovascular Research Foundation
Transcatheter Cardiovascular Therapeutics

1. Sternocostal Aspect Basic Coronary Artery Anatomy
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Sternocostal Aspect
Basic Coronary Artery Anatomy

2. Diaphragmatic Aspect
Basic Coronary Artery Anatomy

3. Sternocostal Aspect Basic Coronary Artery Anatomy
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Sternocostal Aspect
Basic Coronary Artery Anatomy

4. Sternocostal Aspect Basic Coronary Artery Anatomy
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Sternocostal Aspect
Basic Coronary Artery Anatomy

5. Right Coronary Artery Basic Anatomy
Origin Right aortic sinus (lower origin than LCA)
Course Down 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.
Supplies 25% to 35% of Left Ventricle
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6. Right Coronary Artery Other Branches
Conus Artery usually 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.
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7. Right Coronary Artery Other 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.
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8. Right Coronary Artery Catheterization Tools and Techniques
Judkins’ 4-right; clockwise rotation-works 90% of the time. Adjust catheter size to aorta.
Other tools—Amplatz, Noto, Williams
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9. Right Coronary Artery Optimal View(s)
LAO (30) Cranial(30) particularly for distal bifurcation (AP Cranial may be better).
RAO main shaft; cranial enhances distal vessels and very proximal; caudal may help with Shepherd’s crook.
Lateral bifurcations with RV branches-distal bifurcation, particularly with cranial.
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10. LAO Cranial Angiogram of RCA
PDA
Acute Marginal
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11. RAO Angiogram of RCA This is the Bulleted List slide.
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12. Native RCA Lateral View
Demonstrating Origin of Acute Marginal
Acute
Marginal
Main RCA
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13. AP Cranial View of Distal RCA
RPL 2
AV Groove
RPL 1
PDA
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14. RAO Angiogram of Conus Branch
LAD
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15. Left Coronary Artery Left Main Coronary Artery
Origin upper 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 Views LAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUS
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16. 7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
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Sternocostal Aspect
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

17. 7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
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Sternocostal Aspect
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

18. 7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Diaphragmatic Aspect
7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

19. Left Anterior Descending Artery
Course down the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apex.
Branches septals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus (courses like 1st diagonal).
LAD Supplies anterolateral, apex and septum; ~45%-55% of left ventricle.
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20. Left 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%.
Supplies 15%-25% of LV, unless dominant (supplies 40-50% of LV).
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21. Left Coronary Artery Optimal Views
AP (30)Caudal LMCA, proximal LAD, Cx, distal LAD. Poor for mid LAD- RAO may be useful.
AP (40)Cranial LMCA, LAD, diagonals, septals, distal Cx-may need RAO to separate LAD and Cx.
(45)LAO (35) Cranial LMCA, LAD, diagonals, septals, and distal Cx.
(45)LAO (30) Caudal LMCA, Cx,and prox LAD.
Laterals (cranial, caudal) may be helpful.
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22. AP Caudal View of LCA LAD Circ This is the Bulleted List slide.
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23. AP Cranial View of LCA Cx LAD Septal Diagonal
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24. AP Cranial LCA Angiogram
LMCA Cx
Diagonals
Septal
LAD
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25. LAO Cranial View of LCA Circ LAD Diagonal
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26. LAO Caudal View of LCA Median Ramus LAD Circ
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27. 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
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28. 7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Left Dominant Circulation
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7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

29. LCA Angiogram Dominant Cx AP Caudal Prox LAD LM Occluded Median Ramus
Distal LAD OM
Distal Cx
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30. LCA Angiogram-Dominant Cx LAO-Caudal
Prox LAD
Occluded Median Ramus LM
Prox Cx
Distal LAD
LPDA
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31. The Coronary Arteries Are Complementary
Large PDA Small LAD
Huge Cx (posterolaterals)  Small RCA continuation in AV Groove
Etc, etc, etc…..
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32. Wrap Around LAD This is the Bulleted List slide.
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33. Short LAD/Large RCA with Apical Extension
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34. BYPASS GRAFTS
SVG Left 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.
IMA don’t forget to check subclavians.
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All distal vessels must be accounted for; op notes and old films are extremely helpful.

35. BYPASS GRAFTS
Gastroepiploic visceral catheters (Cobra) enter celiac axis and then common hepatic artery and turn down into gastroduodenal. Use guidewire (Terumo) to cannulate the gastroepiploic for selective injections.
Views multiple views to see ostia, shaft, and distal anastomosis.
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All distal vessels must be accounted for; op notes and old films are extremely helpful.

36. Demonstrating Graft Ostium
SVG-OM-LAO Caudal
Demonstrating Graft Ostium
Ostium
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37. Demonstrating Anastomosis
SVG-OM 1 AP Caudal
Demonstrating Anastomosis
SVG
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38. Origin from left subclavian (AP Cranial)
LIMA to LAD
Origin from left subclavian (AP Cranial)
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39. Distal Anastomosis-AP Cranial
LIMA to LAD
Distal Anastomosis-AP Cranial
LIMA
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LAD

40. Left Subclavian Artery Stenosis

41. RIMA to RCA This is the Bulleted List slide.
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42. RIMA to RCA This is the Bulleted List slide.
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43. Occluded Left-sided SVG
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44. Native LCA AP Caudal Stump of original SVG to OM 1
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45. SVG to OM Lesion 2 Lesion 1 This is the Bulleted List slide.
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46. Slight change of view to demonstrate unequivocal severity of lesion
SVG to OM
Slight change of view to demonstrate
unequivocal severity of lesion
Lesion 2
Lesion 1
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47. Multipurpose Technique -LAO
SVG to RCA
Multipurpose Technique -LAO
SVG
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48. AHA/ACC Lesion Classification
TYPE B
Tubular
Eccentric
Moderate tortuousity
Moderately angulated (45-90)
Irregular contour
Moderate-heavy calcification
Total occlusion (< 3 mos)
Ostial
Bifurcation
Thrombus present
TYPE A
Discrete
Concentric
Readily Accessible
Smooth Contour
Little or no calcification
Non-ostial
No major side branch involved
Absence of thrombus
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49. AHA/ACC Lesion Classification
TYPE C
Diffuse
Excessive tortuousity
Extremely angulated
Total occlusion (> 3 mos)
Inability to protect major side branch
Degenerated SVG
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50. Ulcerated Plaque This is the Bulleted List slide.
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51. LCA AP Caudal Severe stenosis Distal LAD with slow flow
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52. Post-NTG-Thrombus has migrated distally but still adherent
Thrombus In LAD
Post-NTG-Thrombus has migrated distally but still adherent
Thrombus
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53. AP Cranial Thrombus In LAD
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54. Embolization of Thrombus During Angiography
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55. (LAO Cranial) “Bone Island” Simulating Thrombus
Calcified Native RCA
(LAO Cranial) “Bone Island” Simulating Thrombus
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56. Myocardial Bridging Intramyocardial Segment Almost always LAD
Occurs in 5-12% of patients
Usually not hemodynamically significant
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57. Myocardial Bridging LCA-RAO Projection LAD Diastole LAD Systole
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LAD Diastole
LAD Systole

58. Coronary Artery Fistula
Origin50% 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%.
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59. Coronary Artery Fistula
LCA-RAO Projection LAD to PA Fistula PA
Fistula
LAD
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60. Anomalous Origins of Coronary Arteries
LCA from PA
Most have severe ischemia early in life
Only 25% survive to adulthood.
Aortography shows large RCA with collaterals to LCA
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61. LCA from PA Large LAD arising RCA from PA Collaterals to LAD
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Collaterals
to LAD

62. Anomalous Origin of LCA from the Right Sinus of Valsalva
Rare
Course relative to great vessels is variable and must be defined. If interarterial, surgical therapy is warranted.
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7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

63. 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
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7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

64. Normal and Anomalous Origins of the Coronary Arteries
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7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

65. Benign Anomalies (0.5-1%) Left Circumflex from right Sinus of Valsalva
Most common “benign” anomaly
Circumflex courses behind aorta
High Anterior Origin of RCA
Above sinotubular ridge
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66. Anomalous Circumflex Artery
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67. Collateral Circulation-Development
Preexisting-20 to 200 um
First 24 hours-passive widening
One day-3 weeks cellular proliferation, luminal diameter increases 10 fold.
3 weeks-6 months more cellular proliferation and development of extracellular matrix; channels may reach 1mm in caliber.
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68. Collateral Circulation-Development
Ischemia and occlusion are the only factors currently recognized to result in significant collateralization.
Usually need very high grade coronary artery occlusion for collaterals to be angiographically apparent.
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69. LCA -AP Cranial LAD Collateral to distal RCA
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Collateral to distal RCA

70. Collateral “Connections”
Occur where coronary arteries are in proximity
Distal LADDistal PDA
Cx AV grooveR AV groove
SeptalSeptal
MarginalMarginal
DiagonalMarginal
Also
Bridging collaterals-associated with chronicity
Kugel’s artery-prox RCA to distal RCA via AV groove
Always look for conus to LAD collaterals when LAD is occluded and appears uncollateralized.
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71. Collateral Development After RCA Occlusion
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7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

72. Collateral Pathways After LAD Occlusion
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7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.

73. Collateral Pathways After Circumflex Occlusion
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74. Classification of Collaterals
Rentrop Grade
0 No epicardial filling at baseline or during balloon inflation
1 No epicardial filling at baseline with partial epicardial filling during balloon inflation
2 Partial baseline filling with partial or complete filling during balloon inflation
3 Complete epicardial filling at baseline
“Recruitable collaterals”—collaterals which can become
angiographically apparent only during occlusion, such as those
observed during PTCA.
Collaterals can be dilated by nitrates, B-adrenergic agents,
NO and prostacyclin
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75. Recruitable Collaterals
RCA Injection during LAD PTCA
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RCA angiogram demonstrates complete filling of LAD.
No collaterals were apparent prior to balloon inflation.

76. 7th Annual Interventional Cardiology Self-Assessment Course at TCT2004
Basic Coronary Artery Anatomy: Frederick Feit, M.D.