Successful coronary stenting in anomalous right coronary artery by using an inner catheter with mother and child technique under multislice CT guidance

Percutaneous coronary intervention of anomalous right coronary arteries arising from the left sinus of Valsalva: a single-centre experience from Northern India

Background

An anomalous right coronary artery (ARCA) arising from the left sinus of Valsalva is an uncommon congenital anomaly. The unusual location, take-off and intramural courses of ARCA pose a considerable technical challenge during percutaneous coronary intervention (PCI).

Aims

We sought to report our experience of PCI of ARCA in 35 cases of atherosclerotic occlusion.

Methods

The PCI database of 35 cases of ARCA was retrospectively analysed. The details about demography, clinical presentation, PCI procedure and clinical follow-up were noted.

Results

The mean age was 56.7±13.5 years. The clinical presentation included stable angina in 45.7%, unstable angina in 20% and acute myocardial infarction in 34.3% of patients. Vascular access was transradial in 37.1% of cases, transfemoral in 60% of cases, and transbrachial in 1 case (2.9%). Judkins left and Amplatz left were commonly used guide catheters. Two patients with balloon-uncrossable, calcified lesions required rotablation-assisted PCI. Intravascular imaging was performed in 12 patients (34.3%). Optical coherence tomography demonstrated a proximal intramural course in 3 patients, and a slit-like orifice in 4 patients. The mean radiation dose and fluoroscopy time were 877±687.3 mGy and 18.8±11.6 minutes, respectively. Twenty-eight (80%) patients had an asymptomatic median follow-up of 49 (interquartile range: 29.0-97.5) months.

Conclusions

We performed successful PCI in a cohort of 35 patients with ARCA, with favourable long-term clinical outcomes. The selection of an appropriate guide catheter and technical skills were important factors in achieving favourable results.

Percutaneous treatment of a CTO in an anomalous right coronary artery: A rupture paved the way for new insights

An anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus, with an interarterial course, has been associated with an increased risk of myocardial ischemia and sudden death. As the exact pathophysiology of AAOCA is not well understood, the clinical management is also not well defined. With increased use of non-invasive imaging, the diagnosis of AAOCA is increasing and the association of anomalous origin and atherosclerotic disease is becoming a more important topic. We report a rare case of AAOCA chronic total occlusion (CTO). A 40-year-old Caucasian man was referred for invasive coronary angiography (ICA) due to typical chest pain and positive myocardial scintigraphy. ICA demonstrated CTO of an anomalous right coronary artery (ARCA) originating from the left side of the ascending aorta with an interarterial course. There was no lesion in the left coronary artery. During the procedure, unexpected rupture of the coronary artery occurred after dilatation with a small balloon at low pressure. The complication in this case was handled with good procedural final result but was an occasion for a food for thought. Coronary artery perforations are rare but life-threatening procedural complications that are usually caused by predisposing anatomical and procedural factors. We issue a warning on the risk of complications during complex percutaneous coronary intervention of these arteries, and we reconsidered the pathophysiology of the anomaly in a way that could change the approach to the disease. Based on this complication, we hypothesized that the wall of the artery could be fragile due to histopathological alterations, which could have a role in the pathophysiology of coronary malignancy. Future autopsy studies should be focused on the analysis of the arterial wall of the patient affected by sudden death with this anomaly.

ST elevation myocardial infarction in patients with anomalous left main coronary artery: Case series and review of the literature

Anomalous left main coronary artery is rare. We present four cases where anomalous left main coronary artery was diagnosed during emergent cardiac catheterization for ST elevation myocardial infarction. Procedural characteristics, technical challenges, and relevant literature are discussed.

Anomalous right coronary artery: case series and review of literature

Anomalous right coronary arteries (ARCA) are extremely rare in general population. Although mostly asymptomatic and recognized incidentally on cardiac catheterizations, they can be catastrophic and can cause sudden cardiac death. Sudden cardiac deaths are more common when the anomalous vessel runs an inter-arterial course between the aorta and the pulmonary artery. Asymptomatic patients with malignant course of anomalous coronaries can pose clinical dilemmas. Based on prior experience, management of asymptomatic ARCA with malignant course should be subjected to a risk-benefit analysis. This case series begins with a brief description of four separate cases of ARCA. They had their origin in the left coronary sinus or off left anterior descending artery (LAD). Three of them had anterior course between aorta and pulmonary trunk, confirmed by coronary CT angiography (CTA). Whereas two of our patients presented with chronic symptoms, two presented as acute cases with electrocardiographically proven STEMI. These cases were managed differently; by conservative, surgical or interventional approaches. All four cases had good final outcomes. This goes to show how different treatment options can be employed in management of complications associated with anomalous coronary arteries. It is also interesting to note that the radial access provides better guide support that is needed to tackle complex lesions. Many operators have been using radial approach for anomalous coronary interventions. We have successfully employed radial technique after failed trans-femoral attempts and also in STEMI situations. Based on our experience, right radial approach appears to be safer and quicker.

Percutaneous coronary intervention with anomalous origin of right coronary artery: case reports and literature review

Percutaneous coronary intervention (PCI) in an anomalous right coronary artery (RCA) can be technically difficult because selective cannulation of the vessel may not be easy. We thereby present two cases with unstable angina pectoris of anomalous originated RCA. The PCI were successfully performed in two patients with a special guiding wire manipulating skill which we called “gone with the flow” combined with balloon anchoring technology, providing excellent angiographic visualization and sound guide support for stent delivery throughout the procedure without severe cardiovascular adverse effects. Our primary data suggested that PCI for geriatric patients with an anomalous origin of RCA accompanied by severe atherosclerotic lesions might also be a safe, available, and feasible strategy.

Successful percutaneous coil embolization of a large and tortuous coronary artery to pulmonary artery fistula

We herein report the case of a 73-year-old woman with a large and tortuous coronary artery to pulmonary artery fistula treated with percutaneous coil embolization. The patient was hospitalized due to unstable angina with an elevated serum troponin-T level. Coronary angiography revealed no significant atherosclerotic stenosis, with a large and tortuous coronary artery to pulmonary artery fistula originating from the proximal portion of the left anterior descending artery. We successfully performed percutaneous coil embolization of the fistula. In this case, 320-slice multidetector computed tomography played a pivotal role in the diagnosis and percutaneous intervention.