Coronary artery trifurcation

Coronary Angiography

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General Principles

Overview

Historical Perspective

Contraindications

Appropriate Use Criteria for Revascularization

Complications

Technique

Film Quality

Anatomy & Projection Angles

Normal Anatomy

Coronary arteries
Dominance
Right System
Left System

Left Main
Left Anterior Descending
Circumflex
Median Ramus

Anatomic Variants

Separate Ostia
Anomalous Origins

Case Example
Fistula

Projection Angles

Standard Views
Left Coronary Artery
Right Coronary Artery

Epicardial Flow & Myocardial Perfusion

Epicardial Flow

TIMI Frame Count

TIMI Flow Grade

TIMI Grade 0 Flow
TIMI Grade 1 Flow
TIMI Grade 2 Flow
TIMI Grade 3 Flow
TIMI Grade 4 Flow
Pulsatile Flow
Deceleration

Myocardial Perfusion

TIMI Myocardial Perfusion Grade

TMP Grade 0
TMP Grade 0.5
TMP Grade 1
TMP Grade 2
TMP Grade 3

Lesion Complexity

ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis

Preprocedural Lesion Morphology

Eccentricity
Irregularity

Ulceration
Intimal Flap
Aneurysm
Sawtooth Pattern
Length
Ostial location
Angulation
Proximal tortuosity
Degenerated SVG
Calcification
Total occlusion
Coronary Artery Thrombus

TIMI Thrombus Grade
TIMI Thrombus Grade 0
TIMI Thrombus Grade 1
TIMI Thrombus Grade 2
TIMI Thrombus Grade 3
TIMI Thrombus Grade 4
TIMI Thrombus Grade 5
TIMI Thrombus Grade 6

Lesion Morphology

Quantitative Coronary Angiography
Definitions of Preprocedural Lesion Morphology
Irregular Lesion
Disease Extent
Arterial Foreshortening
Infarct Related Artery
Restenosis
Degenerated SVG
Collaterals
Aneurysm
Bifurcation
Trifurcation
Ulceration

Left ventriculography

Technique
Quantification of LV Function
Quantification of Mitral Regurgitation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Rim Halaby, M.D. [2]

## Overview

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A trifurcation is defined as a division of a main, parent branch into three daughter branches of at least 2.0 mm.

## Example

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## References

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Coronary Angiography

Coronary Anatomy|

Normal coronary anatomy • Anomalous origins of coronary arteries
(Left coronary artery • Right coronary artery) • Congenital abnormalities of coronary arteries • Coronary artery segments • Cinefilm frame speed • Coronary artery dominance (Left dominance • Right dominance • Co-dominance)

TIMI Flow Grade|

TIMI flow grade 0 • TIMI flow grade 1 • TIMI flow grade 2 • TIMI flow grade 3

TIMI Frame Count|

TFC for SVG • TIMI Myocardial Frame Count • Washout TIMI Frame Count

TIMI Myocardial Perfusion Grade|

TIMI MPG 0 • TIMI MPG 1 • TIMI MPG 2 • TIMI MPG 3

Thrombus Grading|

Thrombus Grade 0 • Thrombus Grade 1 • Thrombus Grade 2 • Thrombus Grade 3 • Thrombus Grade 4 • Thrombus Grade 5 • Thrombus Grade 6

Lesion Complexity|

Type A • Type B1 • Type B2 • Type C

Dissection Classification|

Type A • Type B • Type C • Type D • Type E • Type F

Coronary Collaterals|

Grade 0 • Grade 1 • Grade 2 • Grade 3 • Rentrop and Cohen’s Collateral Classification

Lesion Morphology|

Myocardial bridge •Definitions of Preprocedural Lesion Morphology • Luminal irregularities • Disease extent • Arterial foreshortening • Infarct related artery (Culprit lesion) • Reocclusion • Restenosis • Degenerated saphenous vein graft • Coronary artery fistula

Angiographic complications|

Distal embolization • Coronary spasm • Abrupt closure • Side branch loss • Slow flow • No-reflow • Pulsatile flow • Flow deceleration • Ectasia • Intimal flap • Staining •

Performing Coronary Angiography|

Patient preparation • Catheter selection • Standard angiographic views • High risk groups • Patients with special need • Access site closure (Manual compression • Assisted compression • Closure devices) •

Quantitative Coronary Angiography (QCA)|

Minimal lumen diameter • Percent stenosis • Reference diameter • Lesion length • Residual stenosis • Average reference segment diameter • Plaque area • Plaque volume •

Contrast Media|

High-osmolar contrast media • Iso-osmolar contrast media • Low-osmolar contrast media

Left Ventriculography & Aortography|

Ejection fraction • Aortography • Quantitative Left Ventricular Analysis (LAO projection • RAO projection • LVA) • Left Ventricular Wall Motion Analysis (Normokinesia • Hypokinesia • Akinesia • Dyskinesia • Aneurysm) • Evaluation of mitral regurgitation • Evaluation of aortic regurgitation

Right Heart Catheterization|

Pressure waveforms (Right atrial pressure • Rirght ventricular pressure • Pulmonary artery pressure • Pulmonary artery wedge-pressure) • Endomyocardial biopsy

Complications|

Access site complications • Dumping • Contrast hypersensitivity • Contrast induced nephropathy • Hypotension • Hypertension • Dissection • Vessel perforation • Acute myocardial infarction • Ventricular fibrillation • Cardiac arrest • Stroke • ASD • VSD • Pulmonary emboli • Myocardial rupture • Peripheral arterial emboli • Radiation injury

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