Interventional Cardiology. Группа авторов

      CHAPTER 4

      Optimal Angiographic Views for Coronary Angioplasty

       Flavia Caniato, Francesca Ristalli, Alessio Mattesini, Carlo Di Mario, and Gioel Gabrio Secco

      Angiography has been the keystone tool to assess coronary anatomy, leading to the development of largely applied revascularization techniques such as coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). When CABG was the only revascularization strategy, the main scope of angiography was to detect the presence of significant stenosis and to provide information on vessel distality and contrast run‐off. There was no need to be parsimonious with contrast because no further angiographic procedures were being planned. However, with the development of PCI, angiography has become far more important. In addition to clearly demonstrating the entire length of all epicardial arteries, the focus is to identify the anatomy of the lesion including its extension and the relationship with side branch vessels in order to allow correct planning of the revascularization strategy. The number of views and contrast use is restricted to the minimum required in anticipation of further contrast requirement during intervention. Therefore, angioplasty focused projections should be favored in view of standard acquisitions, carefully selecting the more informative views in order to avoid foreshortening or overlapping of the diseased vessels [1]. The main limitation of angiography is that it can only provide a limited analysis of lumen profile without providing in‐depth information about vessel wall characteristics or the composition of coronary lesions. New intracoronary imaging techniques, namely IVUS and OCT, have been developed to overcome these limitations and will be discussed in subsequent chapters.

Catheter selection

      Since the first human cardiac catheterization, performed by Forssmann in 1929, equipment has undergone considerable evolution and nowadays the miniaturization and refinement of materials allow interventionalists to perform safe and effective selective coronary cannulation also in complex anatomies. The size of sheaths and catheters has seen a dramatic reduction in the last few years: from the 9 French (Fr) guiding catheters used by Gruentzig for the first angioplasties in the late 1970s, now most PCI can be safely performed with a 6 Fr and sometimes 5 Fr guiding catheter using a radial approach [2]; these smaller catheters appear of particular interest in the “transradial era” where transradial PCI has emerged as a gold standard in many centers replacing the transfemoral route in daily practice. Access site, size of the ascending aorta, and origin and take off of the target artery strictly condition the selection of the ideal curve for the catheter. Contemporary diagnostic catheters are preshaped to facilitate intubation of the coronary ostia, in most cases with only minimal catheter manipulation. This facilitates ad hoc angioplasty when angiography shows a suitable pathology, provided that the patient has been adequately informed and prepared.

      Left coronary

Judkins curve catheters are used most widely. Judkins left 4 (JL4) would suit the anatomy of most patients although downsizing to JL3.5 may be required in patients with a smaller diameter of the aorta, such as women, while JL4.5, JL5, or even JL6 with longer secondary curves may be required if the aortic root is dilated,. Selective intubation can be encountered when there is a short left main stem (LMS) or separate origin of the left anterior descending (LAD) and circumflex (Cx) arteries, which may necessitate selecting a catheter with an upwards pointing tip (e.g., JL3.5) for intubation of the LAD and a more horizontal tip (e.g. JL4) for intubation of the Cx. Guiding catheter selection for left coronary artery is shown in Figure 4.1.