Right Selective Coronary Arteriograms :

The right main coronary artery arises from the anterior aortic sinus. It passes forwards and to the right, to emerge between the pulmonary trunk and the right atrium. It then runs inferiorly and to the right in the atrioventricular groove to reach the crux. It then runs on the back of the heart as far as the posterior interventricular groove where it anastomoses with the left coronary artery. In approximately 70% of patients the right coronary is dominant, i.e. it crosses the crux of the heart and supplies part of the left ventricular wall and interventricular septum.

   Left Selective Coronary Arteriograms :

The left main coronary artery arises from the left posterior aortic sinus and runs between the pulmonary trunk and the left atrial appendage. It then turns into the coronary sulcus after dividing into its two major branches - the anterior descending branch which runs in the anterior interventricular groove to the apex of the heart, and the circumflex branch which runs in the left atrioventricular sulcus giving off branches to the upper lateral left ventricular wall and left atrium. This selective coronary arteriogram was again performed using Judkin's technique. Coronary arteriography has become increasingly important with the investigation and surgery of ischaemic heart disease, and the number of examinations performed each year is ever increasing. It is important to note the variations of the normal anatomy and to know the branches so that they can be recognized in any plane.

   Aortic Arch Arteriogram (Left Anterior Oblique View) :

The aorta gives off three branches from the upper aspect of its arch: the brachiocephalic, the left common carotid and the left subclavian. The left anterior oblique projection is used so that the arch and vessel origins are demonstrated more clearly. There are several congenital variations of the distribution of the major vessels, the commonest being a common brachiocephalic trunk giving rise to both common carotid arteries. The brachiocephalic artery is the largest branch of the aorta and its course takes it to lie on the right side of the trachea. In old people, this artery commonly elongates and becomes tortuous, giving rise to a soft tissue impression on the right side of the upper mediastinum on a PA chest x-ray. It divides into the right common carotid and right subclavian arteries at the upper border of the right sternoclavicular joint. The suclavian artery supplying the arm extends from its origin to the outer border of the first rib, where it becomes the axillary artery. The catheter has been introduced into the aortic arch via the femoral route and the contrast medium (water-soluble with an iodine content of around 400 mg/ml) injected under pressure. A lower concentration of iodine of about 280 mg/ml is used for all the following peripheral angiography demonstrated and for the cerebral angiography.

   External Carotid Arteriograms :

The branches of the external carotid artery from its origin are: superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior auricular, superficial temporal and maxillary. The external carotid artery begins at the level of the C3/C4 disc and ascends to the angle of the jaw where it enters the parotid gland to divide into the terminal branches of the superficial temporal and maxillary arteries. One reason for performing selective catheterization of the external carotid is to assess the blood supply to tumours. Two examples of this are the vault meningioma, which often has a dual blood supply from the common carotid as well as the external carotid, and the rare juvenile nasopharyngeal fibroma (fibrohaemangioma). It is possible to inject directly the superficial temporal artery in patients with temporal arteritis to show the position of lesions, which can then be biopsied.

   Subclavian-axillary Arteriogram :

The axillary artery runs from the outer border of the first rib to the lower border of the teres major muscle from whence it becomes the brachial artery. The branches of the subclavian artery are the vertebral, internal thoracic, thyrocervical trunk and costocervical trunk. On the left side of the neck, the four branches arise from the first part of the subclavian artery whereas on the right side the costocervical trunk often springs from the second part. The subclavian artery is divided into its three parts by the scalenus anterior muscle. Note the anastomosis between the suprascapular and acromial arteries. Note also the anastomosis of the circumflex humeral arteries which give branches to the shoulder joint. One of the common reasons for performing this selective arteriogram is to demonstrate compression of the subclavian artery by a cervical rib or fibrous band. Careful positioning of the patient's arm may be needed to show this vascular abnormality.

   Brachial Arteriogram :

The brachial artery is a continuation of the axillary artery; it begins at the lower border of teres major and ends about 1 cm below the elbow joint by dividing into the radial and ulnar arteries. The distal division is often variable with a high take-off point, particularly of the radial artery. The profunda brachii artery is a large vessel which arises from the brachial artery below the teres major muscle. It closely follows the radial nerve, running in the groove covered by the lateral head of the triceps muscle. The ulnar artery is the larger of the two terminal branches of the brachial artery and passes to the medial side of the forearm to cross the flexor retinaculum on the lateral side of the ulnar nerve. The anterior and posterior interosseous arteries arise from the ulnar artery via the common interosseous artery. They descend on the surfaces of the interosseous membrane itself.

   Antero-posterior View of Hand Arteriogram :

The median artery arises from the anterior interosseous artery and accompanies the median nerve. It is of variable size and, when large, may join the superficial palmar arch. The superficial palmar arch is formed mainly by the ulnar artery which crosses on the medial side of the hook of the hamate to spread across the palm and become the arch. The anatomy of the superficial and deep arches is shown. Two pathological conditions which can be visualized on hand arteriography are the digital vessel occlusion seen in Raynaud's disease and the small microaneurysms seen in the collagen disease, polyarteritis nodosa.

   Coeliac Arteriogram :

The coeliac artery comes off the ventral aspect of the abdominal aorta at the level of the T12/L1 disc. The three major branches are: the left gastric, common hepatic and splenic. The common hepatic artery gives off the gastroduodenal artery and continues as the hepatic proper which ascends via the porta hepatis to divide into left and right branches supplying the corresponding lobes of the liver. In the lesser omentum, the hepatic artery lies in front of the portal vein and on the left side of the common bile duct, with its right branch usually crossing behind the common hepatic duct. With recent techniques of catheterization, superselective arteriograms can be performed with subtraction. These are of particular value when looking for pancreatic lesions.