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angulation to the right to project the catheter tip off the spine or a caudal left anterior oblique (LAO, (the so‐called spider) view, are used most often. At least three to four perpendicular views are required to visualize the left coronary tree (Table 4.1 shows the most widely used combinations of views). In many patients these views would suffice, potentially even when proceeding immediately to angioplasty. However, because of variations in patient anatomy, such as increased overlap caused by prominent tortuosity, displacement, or rotation of the heart axis in the chest (e.g. when there is normal anatomic variation, chest wall deformity, previous cardiothoracic surgery, or lung pathology), modification of views or additional views are sometimes required. When a lesion is identified, additional views can be indicated depending on how well the affected coronary segment has been straightened and visualized (Table 4.2).
Table 4.1 Angiographic projections and optimal visualization of left and right coronary artery segments.
| Coronary artery segment | LAO 40–50° Caudal 25–40° (spider) | AP RAO 5–15° Caudal 30° | RAO 30–45° Caudal 30–40° | AP/RAO 5–10° Cranial 35–45° | LAO 35–40° Cranial 25–35° | Lateral ± Caudocrania10–30° | l LAO 45–60° | RAO 30–45° |
|---|---|---|---|---|---|---|---|---|
| LM ostium | ++ | + | + | +++ | +++ | – | – | – |
| LM bifurc | +++ | +++ | ++ | – | – | – | – | – |
| LAD prox | ++ | ++ | +++ | ++ | ++ | + | – | – |
| LAD mid | – | + | + | +++ | ++ | ++ | – | – |
| LAD dist | + | + | +++ | + | – | +++ | – | ++ |
| LAD/DG | ++ | + | – | ++ | +++ | – | – | – |
| LCX prox | + | +++ | +++ | – | – | – | – | – |
| LCX dist | + | + | ++ | +++ | ++ | + | ++ | – |
| OM bifurc | ++ | +++ | ++ | – | – | – | + | – |
| RCA prox | – | – | – | + | +++ | – | ++ | – |
| RCA mid | – | – | – | – | + | +++ | ++ | +++ |
| RCA dist/crux | – | – | – | +++ | +++ | – | ++ | – |
| PDA | – | – | – | +++ | ++ | – | + | ++ |
| PLV | + | – | – | +++ | ++ | + | + | – |
| LIMA anast | + | – | – | – | – | +++ | – | – |
– not recommended; + occasionally useful; ++ very useful; +++ ideal.
AP, anteroposterior; LAD, left anterior descending; LAO, left anterior oblique; LCX, left circumflex; LIMA, left internal mammary artery; OM, obtuse marginal; PDA, posterior descending artery; PLV, posterior left ventricular; RAO, right anterior oblique; RCA, right coronary artery.
Table 4.2 Popular view combinations for diagnostic angiography with benefits and limitations of each view.
| View | Good for visualizing | Limitations |
|---|---|---|
