10.1 Graft, Pulmonary, Aortic & Ventricular Angiography

Graft, Pulmonary, Aortic & Ventricular Angiography

Procedures 1.A.2.b through ventriculography leave the native ostia you already engaged. Bypass-graft angiography, pulmonary angiography, aortography, and left ventriculography are separate studies with different catheters, views, and ways to injure a conduit or a ventricle. Angles, injector recipes, and regurgitation grades below are cath-lab teaching, not unpublished ARRT cutoffs.

Quick Answer: Read the old operative report before you hunt grafts. SVG ostia sit on the ascending aorta; LIMA/RIMA arise from the subclavian — do not engage the IMA aggressively. You need a lateral or RAO to see LIMA-to-LAD. Pulmonary angiography is a right-heart PA injection for PE and AVMs, with extra caution in pulmonary hypertension. Root aortography looks for AR, a dissection flap, anomalous coronaries, and conceptual TAVR workup. LV gram: RAO ~30°, pigtail mid-cavity (not against the wall), MR 1–4+, wall motion named, and no vigorous LV gram into apical thrombus.

Coronary artery bypass graft angiography

A complete native coronary angiogram does not prove a bypass is open. You still have to find every conduit the surgeon sewed.

Saphenous vein grafts (SVG). The proximal hood is usually on the anterior ascending aorta, above the sinuses. A JR4, multipurpose, Amplatz, or a dedicated right or left coronary bypass (RCB/LCB) catheter is walked onto that hood. Right-sided SVGs tend to sit more anterior; left-sided SVGs more leftward and slightly posterior — but the surgeon, not a cartoon, placed the anastomosis. Sequential (jump) grafts have more than one distal target; an injection that fills the first anastomosis and stops is not finished until you see whether the graft continues.

Vein grafts have little native vasoactivity, but degenerate plaque and thrombus years later. Distal embolization from a diagnostic injection is real. Confirm a live aortic waveform before a cine. A buried tip in a degenerated hood is a dissection, not a prettier picture.

Arterial grafts — LIMA, RIMA, radial. The left internal mammary (thoracic) artery (LIMA) arises from the underside of the left subclavian. The RIMA arises from the right subclavian. From femoral access you usually engage the subclavian first, then the IMA ostium with an IMA or JR-type catheter. From left radial, the left subclavian is a shorter path — still not a license to torque. Do not engage aggressively and do not deep-seat. The IMA wall is thin. Subclavian or IMA dissection in a patient whose anterior wall lives on the LIMA is a surgical emergency.

LIMA-to-LAD anastomosis often lies on the anterior surface of the heart. AP or shallow RAO can hide it behind the heart border. A true lateral and a steeper RAO open the distal LIMA and the anastomosis. If you only shoot AP, you can call a patent LIMA uninterpretable or miss a distal kink. A diffusely thread-like IMA (string sign) is competitive flow or a failing conduit — document it; do not force a larger catheter to “open” it.

Radial artery grafts may be a free graft from the aorta (hunt like an SVG) or a composite Y-graft from the LIMA (fills when you inject the LIMA). Radials spasm. Arterial nitrates or calcium-channel vasodilators are physician-directed; they are not a reason to bury the catheter.

The old operative report is not optional. Number of grafts, conduit type (SVG versus LIMA versus RIMA versus radial), targets (LAD, diagonal, OM, PDA, PLV), sequential versus individual, and whether an IMA was used, abandoned, or never harvested — that lives on paper, not on the first aortogram. A “three-vessel bypass” that was LIMA-LAD plus two SVGs is a different hunt from three SVGs and an unused IMA.

Pulmonary angiography

Pulmonary angiography is a right-heart catheterization study. A balloon-tipped or pigtail catheter is advanced to the main PA or selectively into right or left PA. Indications the CI exam still cares about: pulmonary embolism (intraluminal filling defect or abrupt cutoff — CT pulmonary angiography is more common in the ED, but catheter angiography remains the lab’s tool and the platform for catheter-directed therapy) and pulmonary arteriovenous malformations (AVMs) (early venous return, dilated feeding artery). Congenital PA maps and pre-intervention roadmaps use the same skill.

Pulmonary hypertension changes the risk. A large, rapid PA injection into a high-pressure, thin-walled pulmonary arterial tree can cause PA rupture, acute RV strain, and hypotension. Lower volume and flow. Ask the PA systolic pressure before you arm a power injector. Do not treat a main-PA gram like an LV-gram recipe. Watch RV diastolic pressure and systemic blood pressure during the run. Selective RPA or LPA injections cut overlap and contrast load. Air in a PA injector is the same catastrophe as air in an LV injector — purge until the column is solid.

Aortography

A pigtail in the aortic root — sitting in a free cavity, not crammed into a sinus against wall — is aortography. Teaching uses:

• Aortic regurgitation (AR): contrast that fills the LV from the root. Mild AR wisps into the LV and clears; severe AR densely opacifies the LV.
• Dissection flap: a linear filling defect in the root or ascending aorta, true versus false lumen. Do not power-inject into a suspected false lumen.
• Anomalous coronaries: when selective ostial engagement fails, a root shot can show a coronary arising from the wrong sinus or a very high takeoff.
• TAVR workup (conceptual): aortography still shows root geometry, AR, and coronary ostial height in the lab, even though CT is the usual pre-TAVR anatomic gold standard. After implant, aortography looks for paravalvular leak.

Typical teaching is a power-injected pigtail in a free root, not a selective coronary catheter and not a pigtail jammed on the wall (stain, dissection). LAO often opens the ascending aorta and root; the exact angle follows the question you are answering.

Left ventriculography

RAO ~30° is the classic LV gram: anterior, apical, and inferior walls and the mitral valve (the LA sits behind the LV on RAO). LAO adds the lateral wall and a look at the septum. This is angiographic wall-motion language, not a replacement for every echo score.

Pigtail position: mid-cavity, not against the wall. Side-holes should sit in blood. If the loop is on the inferior or anterior endocardium you get PVCs, endocardial staining, and, if you fire anyway, perforation and tamponade. A catheter that ectopically irritates the apex is pulled back, not power-injected “to see if it settles.”

PVCs from the catheter invalidate a beat-to-beat ejection fraction. Post-extrasystolic potentiation makes the post-PVC beat look hypercontractile. Visual or quantitative EF is read on a sinus beat that is not the PVC and not the immediate post-PVC beat.

Ejection fraction may be a visual estimate or quantitative (area-length / centerline-type methods). Visual is fast and operator-dependent; quantitative needs a well-opacified cavity without PVC distortion.

Mitral regurgitation grading (1–4+), teaching:

• 1+ (mild): faint LA contrast that clears promptly.
• 2+ (moderate): LA opacifies but stays less dense than the LV.
• 3+ (moderately severe): LA density approaches the LV; delayed clearing.
• 4+ (severe): LA as dense as or denser than the LV, often with pulmonary-vein filling.

Wall motion: hypokinesis (reduced inward motion), akinesis (none), dyskinesis (paradoxical systolic outward motion). An aneurysm is a discrete dyskinetic sac, often apical after an anterior infarct.

Thrombus is a contraindication to a vigorous LV gram. An akinetic apex after anterior infarction is a clot factory. A high-flow pigtail jet can embolize thrombus to brain or periphery. If thrombus is known or the apex is a dense filling defect, do not “clear the picture” with a larger volume.

Study / catheter / key view / complication

Worked case

CABG 12 years ago: LIMA-LAD, SVG-OM, SVG-PDA. The operative report is in the folder. SVG-OM and SVG-PDA engage from the anterior aorta with a JR4. An IMA catheter is walked into the left subclavian; the IMA ostium is engaged gently. AP does not show the distal LIMA. Lateral and RAO open the LIMA-LAD anastomosis — patent, no string sign. Then an RAO 30° LV gram is requested. Echo last week showed an apical thrombus. Do not fire a vigorous LV gram. Document wall motion by echo or a careful low-volume physician-directed shot if at all; thrombus plus a pigtail jet is stroke. If the same patient later needs a PA gram and PA systolic pressure is 70 mmHg, that is not an LV-gram injector recipe.

Exam traps

• Hunting grafts without the operative report.
• Aggressive IMA engagement from the subclavian.
• Calling a LIMA-LAD anastomosis normal from AP only.
• Power-injecting the PA in severe pulmonary hypertension as if it were an LV cavity.
• LV pigtail against the wall, grading EF on a PVC, or a vigorous LV gram into apical thrombus.
• Injecting a false lumen on a root aortogram.