Traditional medicine

Circumflex artery. Coronary arteries of the heart

Coronary arteries are the two main channels through which blood flows to the heart and its elements.

Another common name for these vessels is coronoid. They surround the contractile muscle from the outside, supplying its structures with oxygen and necessary substances.

Two coronary arteries go to the heart. Let's take a closer look at their anatomy. Right nourishes the ventricle and atrium located on its side, and also carries blood to part of the posterior wall of the left ventricle. It departs from the anterior sinus of Vilsava and is located in the thickness of the adipose tissue on the right of the pulmonary artery. Next, the vessel bends around the myocardium along the atrioventricular groove and continues to the posterior wall of the organ to the longitudinal one. The right coronary artery also reaches the apex of the heart. Along its entire length, it gives one branch to the right ventricle, namely to its anterior, posterior wall and papillary muscles. This vessel also has branches extending to the sinoaricular node and the interventricular septum.

The supply of blood to the left and partially to the right ventricle is provided by the second coronary artery. It arises from the posterior left sinus of Valsava and, heading towards the longitudinal anterior groove, is located between the pulmonary artery and the left atrium. Then it reaches the apex of the heart, bends over it and continues along the posterior surface of the organ.

This vessel is quite wide, but at the same time short. Its length is about 10 mm. The outgoing diagonal branches supply blood to the anterior and lateral surfaces of the left ventricle. There are also several small branches that extend from the vessel at an acute angle. Some of them are septal, located on the anterior surface of the left ventricle, perforating the myocardium and forming a vascular network on almost the entire interventricular septum. The superior of the septal branches extends to the right ventricle, the anterior wall and to its papillary muscle.

The left coronary artery gives off 3 or 4 large branches that are important. The main one is considered anterior descending artery, which is a continuation of the left coronary. Responsible for feeding the anterior wall of the left ventricle and part of the right, as well as the apex of the myocardium. The anterior descending branch extends along the heart muscle and in places plunges into it, and then passes through the fatty tissue of the epicardium.

The second important branch is circumflex artery, which is responsible for feeding the posterior surface of the left ventricle, and the branch that separates from it carries blood to its lateral parts. This vessel departs from the left coronary artery at its very beginning at an angle, runs in a transverse groove in the direction of the obtuse edge of the heart and, bending around it, stretches along the posterior wall of the left ventricle. It then passes into the descending posterior artery and continues to the apex. The circumflex artery has several significant branches that carry blood to the papillary muscles, as well as the walls of the left ventricle. One of the branches also supplies the sinoaricular node.

The anatomy of the coronary arteries is quite complex. The orifices of the right and left vessels extend directly from the aorta, located behind its valve. All cardiac veins connect to coronary sinus, opening on the posterior surface of the right atrium.

Arterial pathologies

Due to the fact that the coronary vessels provide blood supply to the main organ of the human body, their damage leads to the development of coronary disease, as well as myocardial infarction.

The reasons for the deterioration of blood flow through these vessels are atherosclerotic plaques and blood clots that form in the lumen and narrow it, and sometimes causing partial or complete blockage.

The left ventricle of the heart performs the main pumping function, therefore poor blood supply to it often leads to serious complications, disability and even death. If one of the coronary arteries supplying it is blocked, it is necessary to carry out stenting or bypass surgery aimed at restoring blood flow. Depending on which vessel supplies the left ventricle, the following types of blood supply are distinguished:

Right. In this position, the posterior surface of the left ventricle receives blood from the right coronary artery.
Left. With this type of blood supply, the main role is played by the left coronary artery.
Balanced. The posterior wall of the left ventricle is equally supplied by both coronary arteries.

After establishing the type of blood supply, the doctor can determine which of the coronary arteries or its branches is blocked and needs surgical correction.

In order to prevent the development of stenosis and occlusion of the vessels supplying blood to the heart, it is necessary to regularly undergo diagnostics and promptly treat a disease such as atherosclerosis.

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The widespread use of selective coronary angiography and surgical interventions on the coronary arteries of the heart in recent years has made it possible to study the anatomical features of the coronary circulation of a living person and to develop the functional anatomy of the arteries of the heart in relation to revascularization operations in patients with coronary heart disease.

Interventions on the coronary arteries for diagnostic and therapeutic purposes place increased demands on the study of vessels at different levels, taking into account their variants, developmental anomalies, caliber, angles of origin, possible collateral connections, as well as their projections and relationships with surrounding formations.

When systematizing these data, we paid special attention to information from the surgical anatomy of the coronary arteries, basing it on the principle of topographic anatomy in relation to the surgical plan with the division of the coronary arteries of the heart into segments.

The right and left coronary arteries were conventionally divided into three and seven segments, respectively (Fig. 51).

In the right coronary artery, three segments are distinguished: I - a segment of the artery from the mouth to the origin of the branch - the artery of the acute edge of the heart (length from 2 to 3.5 cm); II - section of the artery from the branch of the acute edge of the heart to the origin of the posterior interventricular branch of the right coronary artery (length 2.2-3.8 cm); III - posterior interventricular branch of the right coronary artery.

The initial section of the left coronary artery from the mouth to the place of division into the main branches is designated as segment I (length from 0.7 to 1.8 cm). The first 4 cm of the anterior interventricular branch of the left coronary artery are divided

Rice. 51.Segmental division of coronary

arteries of the heart:

A- right coronary artery; B- left coronary artery

into two segments of 2 cm each - segments II and III. The distal portion of the anterior interventricular branch constituted segment IV. The circumflex branch of the left coronary artery to the origin of the branch of the obtuse edge of the heart is the V segment (length 1.8-2.6 cm). The distal portion of the circumflex branch of the left coronary artery was more often represented by the artery of the obtuse edge of the heart - segment VI. And finally, the diagonal branch of the left coronary artery is the VII segment.

The use of segmental division of the coronary arteries, as our experience has shown, is advisable in the comparative study of the surgical anatomy of the coronary circulation according to selective coronary angiography and surgical interventions, to determine the localization and spread of the pathological process in the arteries of the heart, and is of practical importance when choosing a method of surgical intervention in the case of coronary artery disease hearts.

Rice. 52. Right coronary type of coronary circulation. Well developed posterior interventricular branches

Origin of the coronary arteries . James (1961) suggests calling the aortic sinuses from which the coronary arteries arise the right and left coronary sinuses. The orifices of the coronary arteries are located in the bulb of the ascending aorta at the level of the free edges of the semilunar valves of the aorta or 2-3 cm above or below them (V.V. Kovanov and T.I. Anikina, 1974).

The topography of the sections of the coronary arteries, as indicated by A. S. Zolotukhin (1974), is different and depends on the structure of the heart and chest. According to M. A. Tikhomirov (1899), the mouths of the coronary arteries in the aortic sinuses can be located below the free edge of the valves “abnormally low”, so that the semilunar valves pressed against the aortic wall close the mouths, either at the level of the free edge of the valves, or above them, at the wall of the ascending aorta.

The level of the mouths is of practical importance. With a high position at the time of systole of the left ventricle, the mouth appears

under the impact of a stream of blood, not being covered by the edge of the semilunar valve. According to A.V. Smolyannikov and T.A. Naddachina (1964), this may be one of the reasons for the development of coronary sclerosis.

The right coronary artery in most patients has a main type of division and plays an important role in the vascularization of the heart, especially its posterior diaphragmatic surface. In 25% of patients, we found a predominance of the right coronary artery in the myocardial blood supply (Fig. 52). N.A. Javakhshivili and M.G. Komakhidze (1963) describe the beginning of the right coronary artery in the region of the anterior right sinus of the aorta, indicating that its high origin is rarely observed. The artery enters the coronary sulcus, located behind the base of the pulmonary artery and under the appendage of the right atrium. The section of the artery from the aorta to the acute edge of the heart (segment I of the artery) is adjacent to the wall of the heart and is completely covered with subepicardial fat. The diameter of the first segment of the right coronary artery ranges from 2.1 to 7 mm. Along the artery trunk, epicardial folds filled with adipose tissue form on the anterior surface of the heart in the coronary sulcus. Abundantly developed adipose tissue is noted along the artery from the acute edge of the heart. The atherosclerotically altered trunk of the artery along this length is clearly palpable in the form of a cord. Detection and isolation of the first segment of the right coronary artery on the anterior surface of the heart is usually not difficult.

The first branch of the right coronary artery - the artery of the conus arteriosus, or the fatty artery - leaves directly at the beginning of the coronary sulcus, continuing down to the right at the conus arteriosus, giving branches to the cone and the wall of the pulmonary trunk. In 25.6% of patients, we observed a common origin with the right coronary artery; its mouth was located at the mouth of the right coronary artery. In 18.9% of patients, the mouth of the conus artery was located next to the mouth of the coronary artery, located behind the latter. In these cases, the vessel began directly from the ascending aorta and was only slightly inferior in caliber to the trunk of the right coronary artery.

Muscular branches extend from the first segment of the right coronary artery to the right ventricle of the heart. There are 2-3 vessels located closer to the epicardium in connective tissue couplings on the layer of adipose tissue covering the epicardium.

The other most significant and permanent branch of the right coronary artery is the right marginal artery (a branch of the acute edge of the heart). The artery of the acute edge of the heart, a permanent branch of the right coronary artery, arises in the area of the acute edge of the heart and descends along the lateral surface of the heart to its apex. It supplies blood to the anterolateral wall of the right ventricle, and sometimes to the diaphragmatic part of it. In some patients, the diameter of the artery lumen was about 3 mm, but more often it was 1 mm or less.

Continuing along the coronary sulcus, the right coronary artery bends around the sharp edge of the heart, passes to the posterior diaphragmatic surface of the heart and ends to the left of the posterior interventricular sulcus, not reaching the obtuse edge of the heart (in 64% of patients).

The terminal branch of the right coronary artery - the posterior interventricular branch (III segment) - is located in the posterior interventricular groove, descending along it to the apex of the heart. V.V. Kovanov and T.I. Anikina (1974) distinguish three variants of its distribution: 1) in the upper part of the groove of the same name; 2) along the entire length of this groove to the apex of the heart; 3) the posterior interventricular branch exits onto the anterior surface of the heart. According to our data, only in 14% of patients it reached

apex of the heart, anastomosing with the anterior interventricular branch of the left coronary artery.

From the posterior interventricular branch, 4 to 6 branches extend into the interventricular septum at right angles, supplying blood to the conduction system of the heart.

With the right-sided type of coronary blood supply, 2-3 muscular branches extend to the diaphragmatic surface of the heart from the right coronary artery, running parallel to the posterior interventricular branch of the right coronary artery.

To access the II and III segments of the right coronary artery, it is necessary to lift the heart upward and retract it to the left. The second segment of the artery is located superficially in the coronary sulcus; it can be easily and quickly found and highlighted. The posterior interventricular branch (III segment) is located deep in the interventricular groove and covered with subepicardial fat. When performing operations on the second segment of the right coronary artery, it must be remembered that the wall of the right ventricle in this place is very thin. Therefore, it should be manipulated carefully to avoid perforation.

The left coronary artery, participating in the blood supply to most of the left ventricle, the interventricular septum, as well as the anterior surface of the right ventricle, dominates the blood supply to the heart in 20.8% of patients. Beginning in the left sinus of Valsalva, it is directed from the ascending aorta to the left and down the coronary sulcus of the heart. The initial section of the left coronary artery (I segment) before the bifurcation has a length of at least 8 mm and no more than 18 mm. Isolation of the main trunk of the left coronary artery is difficult because it is hidden by the root of the pulmonary artery.

The short trunk of the left coronary artery with a diameter of 3.5 to 7.5 mm turns to the left between the pulmonary artery and the base of the left appendage of the heart and divides into the anterior interventricular and circumflex branches. (II, III, IV segments of the left coronary artery) is located in the anterior interventricular groove of the heart, along which it is directed to the apex of the heart. It can end at the apex of the heart, but usually (according to our observations, in 80% of patients) it continues on the diaphragmatic surface of the heart, where it meets the terminal branches of the posterior interventricular branch of the right coronary artery and participates in the vascularization of the diaphragmatic surface of the heart. The diameter of the second segment of the artery ranges from 2 to 4.5 mm.

It should be noted that a significant part of the anterior interventricular branch (segments II and III) lies deep, covered with subepicardial fat and muscle bridges. Isolation of the artery in this place requires great care because of the risk of possible damage to its muscular and, most importantly, septal branches going to the interventricular septum. The distal part of the artery (IV segment) is usually located superficially, is clearly visible under a thin layer of subepicardial tissue and is easily distinguished.

From segment II of the left coronary artery, 2 to 4 septal branches extend deep into the myocardium, which participate in the vascularization of the interventricular septum of the heart.

Along the entire length of the anterior interventricular branch of the left coronary artery, 4-8 muscle branches extend to the myocardium of the left and right ventricles. The branches to the right ventricle are smaller in caliber than to the left, although they are the same in size as the muscular branches from the right coronary artery. A significantly larger number of branches extend to the anterolateral wall of the left ventricle. From a functional point of view, the diagonal branches (there are 2 of them, sometimes 3) extending from the II and III segments of the left coronary artery are especially important.

When searching and isolating the anterior interventricular branch, an important landmark is the great vein of the heart, which is located in the anterior interventricular groove to the right of the artery and is easily found under a thin layer of the epicardium.

The circumflex branch of the left coronary artery (V-VI segments) departs at a right angle to the main trunk of the left coronary artery, located in the left coronary sulcus, under the left appendage of the heart. Its permanent branch - the branch of the obtuse edge of the heart - descends over a considerable distance at the left edge of the heart, somewhat posteriorly and in 47.2% of patients reaches the apex of the heart.

After branches depart to the blunt edge of the heart and the posterior surface of the left ventricle, the circumflex branch of the left coronary artery in 20% of patients continues along the coronary groove or along the posterior wall of the left atrium in the form of a thin trunk and reaches the confluence of the inferior vein.

The V segment of the artery is easily detected, which is located in the fatty membrane under the left atrial appendage and covered by the great vein of the heart. The latter sometimes has to be crossed to gain access to the artery trunk.

The distal portion of the circumflex branch (VI segment) is usually located on the posterior surface of the heart and, if surgical intervention is necessary, the heart is elevated and retracted to the left while simultaneously retracting the left appendage of the heart.

The diagonal branch of the left coronary artery (VII segment) runs along the anterior surface of the left ventricle down and to the right, then plunging into the myocardium. The diameter of its initial part is from 1 to 3 mm. With a diameter of less than 1 mm, the vessel is poorly expressed and is more often considered as one of the muscular branches of the anterior interventricular branch of the left coronary artery.

Anatomy of the coronary arteries

Coronary arteries

From an anatomical point of view, the coronary artery system is divided into two parts - right and left. From a surgical perspective, the coronary bed is divided into four parts: the left main coronary artery (trunk), the left anterior descending artery or anterior interventricular branch (LAD) and its branches, the left circumflex coronary artery (OC) and its branches, the right coronary artery (RCA). ) and its branches.

The large coronary arteries form an arterial ring and loop around the heart. The left circumflex and right coronary arteries participate in the formation of the arterial ring, passing along the atrioventricular groove. The formation of the arterial loop of the heart involves the anterior descending artery from the left coronary artery system and the posterior descending artery from the right coronary artery system, or from the left coronary artery system - from the left circumflex artery with a left dominant type of blood supply. The arterial ring and loop are a functional device for the development of collateral circulation of the heart.

Right coronary artery

The right coronary artery arises from the right sinus of Valsalva and runs in the coronary (atrioventricular) groove. In 50% of cases, immediately at the origin, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle. Its second branch is the artery of the sinoatrial node (S-A node artery, SNA). extending from the right coronary artery back at a right angle into the space between the aorta and the wall of the right atrium, and then along its wall to the sinoatrial node. As a branch of the right coronary artery, this artery is found in 59% of cases. In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is blood supply to the sinoatrial node from two arteries (both from the right and from the circumflex). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch (acute marginal artery, acute marginal branch, AMB), usually from one to three, departs from the right coronary artery, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the back of the coronary sulcus and reaches the “cross” of the heart (the intersection of the posterior interventricular and atrioventricular sulcus of the heart).

With the so-called right type of blood supply to the heart, observed in 90% of people, the right coronary artery gives off the posterior descending artery (PDA), which runs along the posterior interventricular groove at various distances, giving off branches to the septum (anastomosing with similar branches from the anterior descending artery, the latter usually longer than the first), the right ventricle and branches to the left ventricle. After the origin of the posterior descending artery (PDA), the RCA continues beyond the cross of the heart as the right posterior atrioventricular branch along the distal part of the left atrioventricular groove, ending in one or more posterolateral branches supplying the diaphragmatic surface of the left ventricle . On the posterior surface of the heart, immediately below the bifurcation, at the junction of the right coronary artery with the posterior interventricular groove, an arterial branch originates from it, which, piercing the interventricular septum, goes to the atrioventricular node - the atrioventricular node artery (AVN).

Left coronary artery

The left coronary artery begins from the left posterior surface of the aortic bulb and exits on the left side of the coronary sulcus. Its main trunk (left main coronary artery, LMCA) is usually short (0-10 mm, diameter varies from 3 to 6 mm) and is divided into the anterior interventricular (left anterior descending artery, LAD) and circumflex artery (LCx) branches . In 30-37% of cases, the third branch arises here - the intermediate artery (ramus intermedius, RI), which crosses obliquely the wall of the left ventricle. The LAD and OB form an angle between themselves that varies from 30 to 180°.

Anterior interventricular branch

The anterior interventricular branch is located in the anterior interventricular groove and goes to the apex, giving off the anterior ventricular branches (diagonal artery, D) and anterior septal branches along the way. In 90% of cases, one to three diagonal branches are determined. The septal branches depart from the anterior interventricular artery at an angle of approximately 90 degrees and pierce the interventricular septum, feeding it. The anterior interventricular branch sometimes enters the thickness of the myocardium and again lies in the groove and along it often reaches the apex of the heart, where in approximately 78% of people it turns posteriorly onto the diaphragmatic surface of the heart and at a short distance (10-15 mm) rises upward along the posterior interventricular groove. In such cases, it forms the posterior ascending branch. Here it often anastomoses with the terminal branches of the posterior interventricular artery - a branch of the right coronary artery.

Circumflex artery

Anatomy of the coronary arteries.

Professor, Doctor of Medicine. Sciences Yu.P. Ostrovsky

At the moment, there are many options for classification of coronary arteries adopted in different countries and centers of the world. But, in our opinion, there are certain terminological differences between them, which creates difficulties in the interpretation of coronary angiography data by specialists of different profiles.

We analyzed the literature on the anatomy and classification of the coronary arteries. Data from literary sources are compared with our own. A working classification of coronary arteries has been developed in accordance with the nomenclature accepted in the English-language literature.

Coronary arteries

Right coronary artery

Right coronary artery(right coronary artery) departs from the right sinus of Valsalva and passes in the coronary (atrioventricular) groove. In 50% of cases, immediately at the place of origin, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle. Its second branch is the artery of the sinoatrial node (S-A node artery, SNA). extending from the right coronary artery back at a right angle into the space between the aorta and the wall of the right atrium, and then along its wall to the sinoatrial node. As a branch of the right coronary artery, this artery is found in 59% of cases. In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is blood supply to the sinoatrial node from two arteries (both from the right and from the circumflex). In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch (acute marginal artery, acute marginal branch, AMB), usually from one to three, departs from the right coronary artery, which in most cases reaches the apex of the heart. Then the artery turns back, lies in the back of the coronary sulcus and reaches the “cross” of the heart (the intersection of the posterior interventricular and atrioventricular sulcus of the heart).

The branches of the right coronary artery vascularize: the right atrium, part of the anterior wall, the entire posterior wall of the right ventricle, a small portion of the posterior wall of the left ventricle, the interatrial septum, the posterior third of the interventricular septum, the papillary muscles of the right ventricle and the posterior papillary muscle of the left ventricle.

Left coronary artery

Left coronary artery(left coronary artery) starts from the left posterior surface of the aortic bulb and exits to the left side of the coronary sulcus. Its main trunk (left main coronary artery, LMCA) is usually short (0-10 mm, diameter varies from 3 to 6 mm) and is divided into the anterior interventricular (left anterior descending artery, LAD) and circumflex artery (LCx) branches . In 30-37% of cases, the third branch arises here - the intermediate artery (ramus intermedius, RI), which crosses obliquely the wall of the left ventricle. The LAD and OB form an angle between themselves that varies from 30 to 180°.

Anterior interventricular branch

The circumflex branch of the left coronary artery is located in the left part of the coronary sulcus and in 38% of cases gives the first branch to the artery of the sinoatrial node, and then the obtuse marginal artery (obtuse marginal branch, OMB), usually from one to three. These fundamentally important arteries supply the free wall of the left ventricle. In the case when there is a right type of blood supply, the circumflex branch gradually becomes thinner, giving off branches to the left ventricle. In the relatively rare left type (10% of cases), it reaches the level of the posterior interventricular groove and forms the posterior interventricular branch. In an even rarer case, the so-called mixed type, there are two posterior ventricular branches of the right coronary and circumflex arteries. The left circumflex artery forms important atrial branches, which include the left atrial circumflex artery (LAC) and the large anastomosing artery of the appendage.

The branches of the left coronary artery vascularize the left atrium, the entire anterior and most of the posterior wall of the left ventricle, part of the anterior wall of the right ventricle, the anterior 2/3 of the interventricular septum and the anterior papillary muscle of the left ventricle.

Types of blood supply to the heart

The type of blood supply to the heart refers to the predominant distribution of the right and left coronary arteries on the posterior surface of the heart.

The anatomical criterion for assessing the predominant type of distribution of the coronary arteries is the avascular zone on the posterior surface of the heart, formed by the intersection of the coronary and interventricular grooves - crux. Depending on which of the arteries - right or left - reaches this zone, the predominant right or left type of blood supply to the heart is distinguished. The artery reaching this zone always gives off the posterior interventricular branch, which runs along the posterior interventricular groove towards the apex of the heart and supplies the posterior part of the interventricular septum. Another anatomical sign is described to determine the predominant type of blood supply. It has been noted that the branch to the atrioventricular node always arises from the predominant artery, i.e. from the artery that is most important in supplying blood to the posterior surface of the heart.

Thus, with predominant right type of blood supply to the heart The right coronary artery supplies the right atrium, right ventricle, posterior part of the interventricular septum, and posterior surface of the left ventricle. The right coronary artery is represented by a large trunk, and the left circumflex artery is poorly expressed.

With predominant left type of blood supply to the heart the right coronary artery is narrow and ends in short branches on the diaphragmatic surface of the right ventricle, and the posterior surface of the left ventricle, the posterior part of the interventricular septum, the atrioventricular node and most of the posterior surface of the ventricle receive blood from the well-defined large left circumflex artery.

In addition, there are also balanced type of blood supply. in which the right and left coronary arteries contribute approximately equally to the blood supply to the posterior surface of the heart.

The concept of “predominant type of blood supply to the heart,” although conditional, is based on the anatomical structure and distribution of the coronary arteries in the heart. Since the mass of the left ventricle is significantly greater than the right, and the left coronary artery always supplies most of the left ventricle, 2/3 of the interventricular septum and the wall of the right ventricle, it is clear that the left coronary artery is the predominant one in all normal hearts. Thus, with any type of coronary blood supply, the left coronary artery is predominant in a physiological sense.

Nevertheless, the concept of “predominant type of blood supply to the heart” is valid, is used to assess anatomical findings during coronary angiography and is of great practical importance in determining indications for myocardial revascularization.

For topical indication of lesion sites, it is proposed to divide the coronary bed into segments

The dotted lines in this diagram highlight the segments of the coronary arteries.

Thus in the left coronary artery in the anterior interventricular branch it is divided into three segments:

1. proximal - from the place of origin of the LAD from the trunk to the first septal perforator or 1DV.

2. average – from 1DV to 2DV.

3. distal – after departure of the 2DV.

In the circumflex artery It is also customary to distinguish three segments:

1. proximal – from the mouth of the OB to 1 VTK.

3. distal – after the 3rd VTC has departed.

Right coronary artery is divided into the following main segments:

1. proximal – from the mouth to 1 VOK

2. medium – from 1 VOC to the acute edge of the heart

3. distal – before the bifurcation of the RCA into the posterior descending and posterolateral arteries.

Coronary angiography

Coronary angiography(coronary angiography) is an X-ray visualization of the coronary vessels after the injection of a radiopaque agent. The X-ray image is simultaneously recorded on 35 mm film or digital media for subsequent analysis.

At the moment, coronary angiography is the “gold standard” for determining the presence or absence of stenoses in coronary disease.

The purpose of coronary angiography is to determine the coronary anatomy and the degree of narrowing of the lumen of the coronary arteries. Information obtained during the procedure includes determination of the location, extent, diameter and contours of the coronary arteries, the presence and degree of coronary obstruction, characterization of the nature of the obstruction (including the presence of atherosclerotic plaque, thrombus, dissection, spasm or myocardial bridge).

The data obtained determine the further tactics of treating the patient: coronary bypass surgery, intervention, drug therapy.

To conduct high-quality angiography, selective catheterization of the right and left coronary arteries is necessary, for which a large variety of diagnostic catheters of various modifications have been created.

The examination is carried out under local anesthesia and NLA through arterial access. The following arterial approaches are generally accepted: femoral arteries, brachial arteries, radial arteries. Transradial access has recently gained a strong position and has become widely used due to its low morbidity and convenience.

After puncture of the artery, diagnostic catheters are inserted through the introducer, followed by selective catheterization of the coronary vessels. The contrast agent is administered in doses using an automatic injector. Filming is performed in standard projections, the catheters and introducer are removed, and a compression bandage is applied.

Basic angiographic projections

When carrying out the procedure, the goal is to obtain the most complete information about the anatomy of the coronary arteries, their morphological characteristics, the presence of changes in the vessels with an accurate determination of the location and nature of the lesions.

To achieve this goal, coronary angiography of the right and left coronary arteries is performed in standard projections. (They are described below). If it is necessary to conduct a more detailed study, shooting is carried out in special projections. This or that projection is optimal for analyzing a certain section of the coronary bed and allows the most accurate identification of morphological features and the presence of pathology of a given segment.

Below are the main angiographic projections indicating the arteries for which these projections are optimal for visualization.

For left coronary artery The following standard projections exist.

1. Right anterior oblique with caudal angulation.

RAO 30, caudal 25.

2. Right anterior oblique projection with cranial angulation.

RAO 30, cranial 20

LAD, its septal and diagonal branches

3. Left anterior oblique with cranial angulation.

LAO 60, cranial 20.

The mouth and distal portion of the LCA trunk, the middle and distal segment of the LAD, septal and diagonal branches, the proximal segment of the OB, the VTK.

Anatomy of the coronary circulation highly variable. The characteristics of the coronary circulation of each person are unique, like fingerprints, therefore each myocardial infarction is “individual”. The depth and prevalence of a heart attack depend on the interweaving of many factors, in particular on the congenital anatomical features of the coronary bed, the degree of development of collaterals, the severity of atherosclerotic lesions, the presence of “prodromes” in the form of angina pectoris, which first appeared during the days preceding the infarction (ischemic “training” of the myocardium), spontaneous or iatrogenic reperfusion, etc.

As is known, heart receives blood from two coronary (coronary) arteries: the right coronary artery and the left coronary artery [respectively a. coronaria sinistra and left coronary artery (LCA)]. These are the first branches of the aorta that arise from its right and left sinuses.

LKA barrel[in English - left main coronary artery (LMCA)] arises from the upper part of the left aortic sinus and goes behind the pulmonary trunk. The diameter of the LCA trunk is from 3 to 6 mm, the length is up to 10 mm. Typically, the LCA trunk is divided into two branches: the anterior interventricular branch (AIV) and the circumflex branch (Fig. 4.11). In 1/3 of cases, the LMCA trunk is divided not into two, but into three vessels: the anterior interventricular, circumflex and median (intermediate) branches. In this case, the median branch (ramus medianus) is located between the anterior interventricular and circumflex branches of the LCA.
This vessel- analogous to the first diagonal branch (see below) and usually supplies the anterolateral parts of the left ventricle.

Anterior interventricular (descending) branch of the LCA follows the anterior interventricular groove (sulcus interventricularis anterior) towards the apex of the heart. In the English-language literature, this vessel is called the left anterior descending artery: left anterior descending artery (LAD). We will adhere to the more anatomically accurate (F. H. Netter, 1987) and accepted in Russian literature term “anterior interventricular branch” (O. V. Fedotov et al., 1985; S. S. Mikhailov, 1987). At the same time, when describing coronary angiograms, it is better to use the term “anterior interventricular artery” to simplify the name of its branches.

Main branches last- septal (penetrating, septal) and diagonal. The septal branches depart from the PMV at a right angle and deepen into the thickness of the interventricular septum, where they anastomose with similar branches arising inferiorly from the posterior interventricular branch of the right coronary artery (RCA). These branches may differ in number, length, direction. Sometimes there is a large first septal branch (running either vertically or horizontally - as if parallel to the PMV), from which branches extend to the septum. Note that of all regions of the heart, the interventricular septum of the heart has the densest vascular network. The diagonal branches of the PMV pass along the anterolateral surface of the heart, which they supply with blood. There are from one to three such branches.

In 3/4 of cases PMV does not end in the area of the apex, but, bending around the latter on the right, wraps around the diaphragmatic surface of the posterior wall of the left ventricle, supplying blood, respectively, to both the apex and partially the posterior diaphragmatic sections of the left ventricle. This explains the appearance of a Q wave on the ECG in lead aVF in a patient with a large anterior infarction. In other cases, ending at the level or not reaching the apex of the heart, the PMV does not play a significant role in its blood supply. The apex then receives blood from the posterior interventricular branch of the RCA.

Proximal area front The interventricular branch (IVB) of the LCA is the segment from the mouth of this branch to the departure of the first septal (penetrating, septal) branch or to the departure of the first diagonal branch (less strict criterion). Accordingly, the middle section is a segment of the PMV from the end of the proximal section to the origin of the second or third diagonal branch. Next is the distal portion of the PMV. When there is only one diagonal branch, the boundaries of the middle and distal sections are determined approximately.

Educational video of blood supply to the heart (anatomy of arteries and veins)

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Arteries of the heart move away from aortic bulbs,bulbils aortae, - the initial expanded section of the ascending aorta and, like a crown, surround the heart, and therefore are called the coronary arteries. The right coronary artery begins at the level of the right aortic sinus, and the left coronary artery begins at the level of its left sinus. Both arteries depart from the aorta below the free (upper) edges of the semilunar valves, therefore, during contraction (systole) of the ventricles, the valves cover the openings of the arteries and almost do not allow blood to pass to the heart. When the ventricles relax (diastole), the sinuses fill with blood, closing its path from the aorta back to the left ventricle, and at the same time opening the access of blood to the vessels of the heart.

Right coronary artery,a. corondria dextra, goes to the right under the appendage of the right atrium, lies in the coronary groove, goes around the right pulmonary surface of the heart, then follows along its posterior surface to the left, where its end anastomoses with the circumflex branch of the left coronary artery. The largest branch of the right coronary artery is posterior interventricular branch, d.interventrlculdris posterior, which is directed along the groove of the heart of the same name towards its apex. The branches of the right coronary artery supply blood to the wall of the right ventricle and atrium, the posterior part of the interventricular septum, the papillary muscles of the right ventricle, the posterior papillary muscle of the left ventricle, the sinoatrial and atrioventricular nodes of the conduction system of the heart.

Left coronary artery,a. corondria sinistra, slightly thicker than the right one. Located between the beginning of the pulmonary trunk and the left atrial appendage, it is divided into two branches: anterior interventricular branch, d.interventriculdrls anterior, And circumflex branch, g.circumflexus. The latter, which is a continuation of the main trunk of the coronary artery, bends around the heart to the left, located in its coronary sulcus, where on the posterior surface of the organ it anastomoses with the right coronary artery. The anterior interventricular branch follows the same groove of the heart towards its apex. In the area of the cardiac notch, it sometimes passes to the diaphragmatic surface of the heart, where it anastomoses with the terminal portion of the posterior interventricular branch of the right coronary artery. Branches of the left coronary artery supply the wall of the left ventricle, including the papillary muscles, most of the interventricular septum, the anterior wall of the right ventricle, and the wall of the left atrium.

The branches of the right and left coronary arteries, connecting, form two arterial rings in the heart: a transverse one, located in the coronary groove, and a longitudinal one, the vessels of which are located in the anterior and posterior interventricular grooves.

The branches of the coronary arteries provide blood supply to all layers of the walls of the heart. In the myocardium, where the level of oxidative processes is highest, microvessels anastomosing among themselves repeat the course of the muscle fiber bundles of its layers.

There are different options for the distribution of branches of the coronary arteries, which are called types of blood supply to the heart. The main ones are the following: right coronary, when most parts of the heart are supplied with blood by the branches of the right coronary artery; left coronary, when most of the heart receives blood from the branches of the left coronary artery, and middle, or uniform, in which both coronary arteries evenly participate in the blood supply to the walls of the heart. There are also transitional types of blood supply to the heart - middle-right and middle-left. It is generally accepted that among all types of blood supply to the heart, the middle-right type is predominant.

Variations and anomalies in the position and branching of the coronary arteries are possible. They manifest themselves in changes in the origin and number of coronary arteries. Thus, the latter can arise from the aopfbi directly above the semilunar valves or much higher - from the left subclavian artery, and not from the aorta. The coronary artery may be the only one, that is, unpaired, there may be 3-4 coronary arteries, and not two: two arteries depart to the right and left of the aorta, or two from the aorta and two from the left subclavian artery.

Along with the coronary arteries, non-permanent (accessory) arteries go to the heart (especially to the pericardium). These can be the mediastinal-pericardial branches (upper, middle and lower) of the internal thoracic artery, branches of the pericardial-phragmatic artery, branches extending from the concave surface of the glacial aorta, etc.

Veins of the heart more numerous than arteries. Most of the large veins of the heart are collected into one common wide venous vessel - coronary sinus,sinus corondrius (remnant of the embryonic left common cardinal vein). The sinus is located in the coronary groove on the posterior surface of the heart and opens into the right atrium below and anterior to the opening of the inferior vena cava (between its valve and the interatrial septum). The tributaries of the coronary sinus are 5 veins: 1) great vein of the heart,v. cordis [ cardldca] magna, which begins at the apex of the heart on its anterior surface, lies in the anterior interventricular groove next to the anterior interventricular branch of the left coronary artery, then at the level of the coronary groove turns to the left, passes under the circumflex branch of the left coronary artery, lies in the coronary groove on the posterior surface of the heart, where it continues into the coronary sinus. The vein collects blood from the veins of the anterior surface of both ventricles and the interventricular septum. The veins of the posterior surface of the left atrium and left ventricle also flow into the great vein of the heart; 2) middle vein of the heart,v. cordis [ cardidca] media, is formed in the region of the posterior surface of the apex of the heart, rises up the posterior interventricular groove (adjacent to the posterior interventricular branch of the right coronary artery) and flows into the coronary sinus; 3) small vein of the heart,v. cordis [ cardidca] pdrva, begins on the right pulmonary surface of the right ventricle, rises upward, lies in the coronary groove on the diaphragmatic surface of the heart and flows into the coronary sinus; it collects blood mainly from the right half of the heart; 4) posterior vein of the left ventricle,And.posterior ventriculi sinistri [ v. ventriculi sinistri posterior], formed from several veins on the posterior surface of the left ventricle, closer to the apex of the heart, and flows into the coronary sinus or great vein of the heart; 5) oblique vein of the left atrium,v. obliqua dtrii sinistri, follows from top to bottom along the posterior surface of the left atrium and flows into the coronary sinus.

In addition to the veins that flow into the coronary sinus, the heart has veins that open directly into the right atrium. This anterior veins of the heart,uv. cordis [ cardidcae] anteriorcs, collecting blood from the anterior wall of the right ventricle. They head up to the base of the heart and open into the right atrium. Smallest veins of the heart(tebesian veins), vv. cordis [ cardidcae] minimae, only 20-30, begin in the thickness of the walls of the heart and flow directly into the right atrium and partially into the ventricles and left atrium through openings of the smallest veins,foramina vendrum minimdrum.

Lymphatic bed The walls of the heart consist of lymphatic capillaries located in the form of networks in the endocardium, myocardium and epicardium. Lymph from the endocardium and myocardium flows into the superficial network of lymphatic capillaries and the plexus of lymphatic vessels located in the epicardium. By connecting with each other, the lymphatic vessels enlarge and form the two main vessels of the heart, through which the lymph flows to the regional lymph nodes. Left lymphatic vessel The heart is formed from the fusion of the lymphatic vessels of the anterior surfaces of the right and left ventricles, the left pulmonary and posterior surfaces of the left ventricle. It follows from the left ventricle to the right, passes behind the pulmonary trunk and flows into one of the lower tracheobronchial lymph nodes. Right lymphatic vessel The heart is formed from the lymphatic vessels of the anterior and posterior surfaces of the right ventricle, is directed from right to left along the anterior semicircle of the pulmonary trunk and flows into one of the anterior mediastinal lymph nodes located at the ligament arteriosus. Small lymphatic vessels through which lymph flows from the walls of the atria flow into the nearby anterior mediastinal lymph nodes.

The coronary arteries are the only branches of the ascending aorta that supply blood to all structures in the pericardial cavity. Typically, the two ostia of the coronary artery are located in the center of the left and right (anterior) sinuses of the aortic valve. The posterior sinus of the aortic valve does not contain the coronary ostium and is usually referred to as a non-coronary sinus.

Left coronary artery

The left coronary artery arises from an ostium located in the left coronary sinus of the aorta, and after one initial trunk (left main coronary artery) of variable length and size, it passes into the anterior interventricular branch (LAD) of the left coronary artery and the circumflex branch (OB) of the left coronary artery .

The LAD left coronary artery runs along the anterior interventricular groove, has several superficial (diagonal) and multiple deep (septal) perforating branches and, as a rule, reaches the apex of the heart.

In some individuals, the diagonal branch may have a very proximal take-off, so that the left main (LM) produces three instead of two branches. In this case, an additional artery arising from the LM arises between the LAD and OB coronary arteries and is called the intermediate coronary artery.

The left circumflex coronary artery courses in the left atrioventricular groove and usually has 1 or more branches that reach the obtuse edge of the heart (obtuse edges).

The LAD coronary artery supplies blood to the anterior wall of the left ventricle through its diagonal branches, the anterior two-thirds of the interventricular septum through its septal perforator branches, and usually the apex of the heart through its terminal branches. The OB of the coronary artery supplies blood to the lateral and posterior walls of the left ventricle through its obtuse marginal branches.

Right coronary artery

The right coronary artery (RCA) arises from the ostium located in the right coronary sinus of the aorta and passes through the right atrioventricular groove to reach the sacrum (the junction of the atrioventricular groove and the posterior interventricular groove) of the heart. It supplies blood to the inferior (diaphragmatic) wall of the left ventricle and often the posterior third of the interventricular septum, as well as the free wall of the right ventricle through its right ventricular (acute marginal) branches.

The posterior descending branch of the RCA supplies the posterior third of the interventricular septum. The posterolateral branch of the RCA supplies most of the basal portion of the posterolateral wall of the left ventricle.

Arterial dominance

The dominance of the left or right coronary artery is determined by the origin of the atrioventricular nodal artery in the region of the heart. The atrioventricular node artery arises from the RCA in approximately 90% of the population and the OB coronary artery in the remaining 10%.

The dominant coronary artery also gives rise to the posterior descending coronary artery, which runs in the posterior interventricular groove and provides branches of the septal septum to the posterior third of the interventricular septum. In individuals, both the RCA and OB together give rise to the descending coronary artery. In these cases, the coronary arterial system is called codominant.

Variations in normal coronary artery anatomy

Absence of the left main coronary artery with separate origin of the LAD and OB coronary arteries from the left coronary sinus of the aorta is found in approximately 1% of people who undergo angiography and is considered a normal variant.

In addition, one or more infundibular (conal) arteries may arise from a separate ostium in the aorta. In other cases of normal cardiac structure, 5 separate conal artery ostia have been reported. Small changes in the location of the orifice in the coronary sinuses of the aorta are observed quite often and have no clinical significance.

Anomalies of the coronary arteries

The list below discusses the classification of the major isolated coronary artery anomalies. As seen, coronary artery anomalies may include abnormalities in the number, origin and/or course, termination or structure of the epicardial coronary arteries.

Normal anatomy options include the following:

Separate origin of LAD and OB from the left coronary sinus

Minor changes in the position of the ostium in the coronary sinus

Separate origin of conal branches

Abnormal variations regarding quantity include the following:

Duplication of permanent residence

RCA duplication (single or double ostium)

Anomalous discharge includes the following:

Origin from the pulmonary trunk

Origin from the left or right ventricle

Origin from the bronchus / internal mammary gland / subclavian / right carotid artery / innominate artery

High rise (more than 1 cm above the sinotubular junction)

An abnormal discharge may include the following:

Single process: (1) from the right coronary sinus (RCA continues as OB and LAD, RCA gives off LM, RCA gives off LAD and OB) and (2) from the left coronary sinus (LM gives off LAD, OB and RCA, OB continues as RCA, OB gives to RCA, LAD gives to RCA)

Departure of the LAD from the RCA

Departure of the OB from the RCA

Origin of the LAD from the right coronary sinus

Origin of the OB from the right coronary sinus

Origin of the RCA from the left coronary sinus

Abnormal arterial endings may include the following:

Fistulas to the right/left ventricle

Fistulas to the right/left atrium

Fistulas to the coronary sinus

Fistulas to the pulmonary artery

Abnormal coronary structures include the following:

Abnormal number of arteries

In some people, certain areas of the left ventricle may have more than one coronary artery. Cases of duplication of the LAD coronary artery, OB of the coronary artery and RCA were found.

Double anterior interventricular branch of the left coronary artery

The double LAD coronary artery consists of one short and another long artery. This anomaly can be classified into several different types.

In the most common form (type I), the short and long LAD coronary arteries arise from the normal LAD coronary artery. The shorter artery then passes through the anterior interventricular groove and ends abruptly before reaching the apex.

However, the longer artery passes along the anterior epicardial surface of the left ventricle and returns to the anterior interventricular groove in its distal third, and then continues to the apex. All diagonal branches arise from the longer artery.

In type II, the long coronary arteries of the LAD pass along the anterior surface of the right ventricle rather than the left.

In a type III double LAD coronary artery, the long artery has at least a partial intramyocardial (pontine) course. The difference from types I and II is that septal perforators arise from the long LAD, and diagonals arise from the short LAD coronary artery.

In type IV, the short LAD coronary artery arises from the LM coronary artery, and the long artery abnormally arises from the RCA and courses to the left side anterior to the right ventricular tract.

In recent years, with the increased use of coronary computed tomography angiography (CT-A), additional variants of dual LAD have been discovered. One case described in detail a type IV variant in which an abnormal long LAD originated independently of the right coronary sinus and reached the distal anterior interventricular groove, passing through the crista supraventricularis of the retina (type V).

Duplicate right coronary artery

Duplication of the RCA has been documented with both single and double ostia in the right coronary sinus. The redundant vessels may pass together in the right atrioventricular groove or have separate courses with a single movement along the epicardial surface of the right ventricle. Both blood vessels give rise to right ventricular branches, and, as a rule, the posterior descending coronary artery begins in one of them.