What are the recommended angiography views?

Recommended Angiography Views

Standard angiographic views should include imaging of the iliac, femoral, and tibial bifurcations in profile without vessel overlap, with selective or super selective catheter placement to enhance imaging quality and reduce contrast dose. 1

Coronary Angiography Views

Essential Views

• Left coronary artery system:

  • Left anterior oblique (LAO) with cranial angulation
  • Right anterior oblique (RAO) with caudal angulation
  • AP cranial view
  • Lateral view

• Right coronary artery system:

  • LAO view
  • RAO view
  • Lateral view

Technical Requirements

• Digital subtraction angiography is recommended for enhanced imaging capabilities compared with conventional unsubtracted contrast angiography 1
• Selective or super selective catheter placement is indicated to enhance imaging, reduce contrast dose, and improve sensitivity and specificity 1
• The diagnostic lower extremity arteriogram should image the iliac, femoral, and tibial bifurcations in profile without vessel overlap 1
• When the significance of an obstructive lesion is ambiguous, transstenotic pressure gradients and supplementary angulated views should be obtained 1

Documentation Requirements

The angiographic report should include:

• Complete assessment of all vascular segments, including those uninvolved by significant lesions 1
• Documentation of specific features such as clot, aneurysm, collaterals, and spasm 1
• Analysis of vascular conduits (coronary bypass grafts, left internal thoracic grafts) including:
  • Patency of the origin
  • Body and anastomotic site
  • Flow pattern
  • Other abnormalities 1

Peripheral Angiography Considerations

For peripheral artery disease (PAD):

• Complete anatomic assessment of the affected arterial territory is essential 1
• Imaging should include the occlusive lesion as well as arterial inflow and outflow 1
• Digital subtraction angiography is preferred for enhanced imaging 1

Patient Preparation and Safety

Before performing contrast angiography:

• Document history of contrast reactions and administer appropriate pretreatment if necessary 1
• Perform a full history and complete vascular examination to optimize access site decisions 1
• Patients with baseline renal insufficiency should receive hydration 1
• Consider n-acetylcysteine for patients with creatinine >2.0 mg/dL 1
• Follow-up evaluation within 2 weeks after contrast angiography is recommended to detect delayed adverse effects 1

Alternative Imaging Modalities

While conventional angiography remains the gold standard for coronary artery disease 2, other modalities may be considered:

• Magnetic Resonance Angiography (MRA):

  • Useful for diagnosing anatomic location and degree of stenosis 1
  • Should be performed with gadolinium enhancement 1
  • Particularly useful for selecting patients for endovascular intervention 1
  • Provides both anatomic and physiologic information 3

• Computed Tomography Angiography (CTA):

  • May be considered as a substitute for MRA in patients with contraindications 1
  • Can be used to diagnose anatomic location and presence of significant stenosis 1

Special Considerations

• Noninvasive imaging modalities (MRA, CTA, color flow duplex) may be used before invasive imaging to develop an individualized diagnostic plan 1
• Cerebral angiography remains essential for evaluating patients with acute cerebral ischemia, particularly beyond the 3-hour time window for intravenous alteplase 4
• For coronary angiography, commercial laboratory systems can provide semiautomated reports with graphic presentations of coronary arterial anatomy 1

Pitfalls to Avoid

• Inadequate visualization of vessel bifurcations
• Vessel overlap that obscures critical anatomy
• Insufficient views to fully characterize ambiguous lesions
• Excessive contrast dose in patients with renal insufficiency
• Failure to document all vascular segments, including those without significant lesions
• Neglecting to obtain supplementary angulated views when lesion significance is ambiguous