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Radiographic Anatomy of the Coronary Arteries

Coming from a centre of excellence in the United States, this lavishly produced book looks most inviting (provided it is a gift, for it is very expensive). It is filled with coronary angiograms, many of which have an explanatory line drawing alongside. This approach promises well, and we find the contents divided into three parts; orientation, normal coronary anatomy, and abnormal coronary anatomy. The illustrations come from large-film coronary arteriograms, which improve the quality of illustration although they have lost their transient popularity in practice. Cineangiograms, which allow optimal projection of individual anatomy and more sensitive appreciation of the severity of difficult lesions because of the rapid film sequence, are now preferred in most centres. Dual use of still film and cine is to be deprecated on account of the greater hazard to the patient caused by the longer procedure. The book was designed for students and physicians who do not themselves perform coronary arteriography but who need to have a better understanding, and it fulfils this need by providing a clear description of the normal anatomy with illustrations and with emphasis on the "circle loop" concept, which is a most helpful one to the novice. Such a book is no substitute for personal practice either in carrying out coronary angiography or in interpretation. The serious student will be disappointed. For example, in the chapter on coronary anatomy in left ventricular aneurysm, aneurysm is dismissed with the comment that the angiographic characteristics of left ventricular aneurysm "have been well defined"as though the recognition of aneurysms were easy. Both of the chosen illustrations of aneurysm are misleading because the distal part of the left anterior descending coronary artery is filled (which is atypical) and in the second there is only a severe stenosis at the origin of the anterior descending artery rather than the complete occlusion which is the usual finding. In view of the difficulty frequently encountered in distinguishing a true aneurysm from a large area of dyskinesia with surviving muscle in the wall, this chapter is hardly helpful. Next we read that akinetic or dyskinetic segments "usually correlate best with areas of myocardium which are thinned and replaced by fibrous tissue." Nowadays the use of intervention angiography, with correlation of the site and reversibility of segmental dyskinesia with the segmental coronary anatomy, is an essential part of the interpretation of coronary angiograms but receives no mention. Omissions are many. There is no mention of coronary spasm and its differentiation from organic narrowing. Only atherosclerotic coronary disease receives mention, so we find no examples of the numerous though rare causes of non-atheromatous coronary disease, both congenital and acquired. No attention is given to finding normal coronary arteries, with the possibilities of embolism and their sources, and all the other possible explanations including malinterpretation that should instantly enter the operator's mind. We find no "'rogues' gallery" of coronary dissection or catheter-induced emboli. These provide distinctive pictures and should be found in such an atlas if the novice is not to learn the mechanism and appearance through personal achievement in this sphere. This atlas lacks the penetrating detail and guidance in interpretation which would be welcome to many working in clinical cardiology and coronary angiography, and its usefulness is really limited to readers who seek only a superficial appreciation of the subject.