|Year : 2013 | Volume
| Issue : 2 | Page : 59-61
PCI in ARCA
Department of Cardiology, Bhopal Memorial Hospital and Research Centre, Bhopal, Madhya Pradesh, India
|Date of Web Publication||21-Sep-2013|
E-7/HIG 748, Arera Colony, Bhopal - 462 016, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Angioplasty of anomalous coronary arteries can be technically challenging because of the difficulty in selectively cannulating the aberrant vessel. I present my experience with angioplasty of an anomalous right coronary artery. A 6- Fr amplatz left 1 guiding catheter was used to obtain stable position in the right coronary artery and angioplasty was performed.
Keywords: Amplatz guiding, anomalous RCA, PCI
|How to cite this article:|
Nagori M. PCI in ARCA. Heart India 2013;1:59-61
| Introduction|| |
Anomalous origin of coronary arteries is observed in 0.2-.2% of patients undergoing cardiac catheterization. , The incidence of the right coronary artery (RCA) from left sinus of Valsalva is reported in various angiographic series to be 0.02-0.17%.  It is not rare to see individuals in late adulthood presenting with an anomalous RCA from the left sinus of Valsalva with coexistent atherosclerotic disease.  Because of the unusual location and the noncircular coronary orifice of this anomaly, selective catheterization and percutaneous coronary intervention (PCI) may be technically challenging.
| Case Report|| |
A 68 year-old male was admitted at our hospital with complaints of chest pain and sweating for last 12 hours. He had an episode of chest pain 4 years back. His risk factors included hypertension and smoking habit. On admission, physical examination revealed a BP of 190/60 and a pulse rate of 86/min. ECG showed ST coving in anterior leads; routine blood examination was normal but Troponin T was found to be 1.59 ng/ml. Diagnosis of non-ST elevation myocardial infarction was made.
Coronary angiography was then done by the femoral approach. Left coronary angiography with a 6 Fr catheter revealed the left descending coronary artery (LAD) significantly stenosed in the proximal part whereas the non-dominant circumflex was free of any significant obstruction. During the diagnostic procedure the RCA could not be cannulated with a 4.0 Judkins right and the amplatz right coronary catheters. An aortic root angiogram was then performed in an attempt to identify the origin of the RCA. The nonselective injection of the ascending aorta with a 1.0 amplatz left coronary catheter revealed an aberrant origin of the RCA from the left sinus of the Valsalva, near the origin of the left main coronary artery [Figure 1].
|Figure 1: LAO cranial view of anomalous RCA from left sinus of valsalva showing stenosis in distal segment|
Click here to view
RCA showed significant diffuse stenosis. Staged PCI was being planned for the two diseased vessels. The Initially easier LAD lesion was dealt with a BMS.
During next sitting the RCA lesion was handled. A 7 Fr arterial sheath was used. A 7 Fr left amplatz 1 guiding catheter was then selectively advanced into the anomalously originating RCA. The stenosis of the RCA was successfully crossed with a 0.014 inch whisper ES (Abbott Vascular, Santa Clara, California) wire. The lesion was predialated with a 2 × 11 sprinter balloon (Medtronic, Santa Rosa, California) @ 8 ATM and then two sequential stents prozeta 2.75 × 23 and prozeta 2.75 × 28, were successfully deployed across the stenosis @ 14 ATM. The lesion was then postdialated with a noncompliant balloon of the size 3 × 11 at high pressure. A final diagnostic angiogram revealed TIMI3 flow [Figure 2]. The subsequent clinical outcomes during hospitalization were normal. The patient was discharged.
| Discussion|| |
Although the overall percentage of coronary anomalies is relatively low, interventional cardiologists will often encounter unusual cases. Selective cannulation of aberrant arteries can be difficult and time-consuming. Knowledge of variations in coronary artery origin can help in selecting appropriate catheters for diagnostic and therapeutic intervention.
Anomalous origin of RCA from the left sinus of Valsalva (ARCA) is most commonly situated anterior and cephalad to the left main coronary artery. It typically makes an acute caudal and right turn anterior to the aorta and between the great vessels, and then proceeds to the right atrioventricular groove.
The presence of an ARCA associated with unusual chest pain or syncope, or provocable inferior ischemia in a young patient requires surgical correction. The ARCA may be considered to be maliciously anomalous, because a decrease in coronary blood flow may lead to acute myocardial ischemia resulting in cardiac arrhythmias and sudden death. 
In the presence of coexistent atherosclerotic disease, an ARCA, as in our case, may make coronary cannulation and establishing backup support a challenge due to the anterior location of the ostium in the left sinus, the tortuous proximal portion, and initial anterior-caudal and rightward course. Topaz et al, have described various aspects of orifice configuration, anatomy of the artery, location of atherosclerotic lesions and also guiding catheter selection. Thus, knowledge of such variations is important for catheter-based treatment or bypass surgery.
There are several case reports of PCI performed on ARCA. A variety of guiding catheters have been used and advocated. Oral et al. stated that stable support could not be accomplished with the use of an amplatz AL-2 guiding catheter and that they were unable to advance the balloon catheter into the anomalous coronary artery. Cohen et al. reported successful stenting in two cases of anomalous RCA with the use of a 6- Fr Judkins left 5.0 cm guiding catheter.
Other authors reported variable success of PCI with different catheters which includes Judkins left catheters [ JL]  and their longer and shorter variants as well as amplatz left catheter [AL-1 and AL-2].  A modification of the AL-1 consisting of a right angled deviation of the tip (Leya Catheter) has also been used successfully in some cases  by Qayyum et al. A modification of an extra-support left coronary guiding catheter for cannulation of the ARCA is described by Rosen et al, Praharaj and Raj have described stenting of ARCA using the Voda guide which was inverted over the LCS, so that the tip is faced upward, rightward, and anteriorly. This gave stable intubation and coaxiality.  Dr. Seth  in an editorial described an inverted Judkins technique with the 0.035 inch guide wire looping up in the aortic root after hitting the coronary sinus; an undersized Judkins left 3.0 or 3.5 guide catheter is advanced with a clockwise twist so that the catheter inverts itself, pointing up with the secondary curve resting on the left coronary cusp. In this position the tip will point anteriorly giving the best coaxiality and support.
In our patient, selective cannulation attempts with various curve guiding right and left Judkins catheters were unsuccessful. Eventually selective cannulation was achieved with a 6-Fr amplatz left 1 guiding catheter and thereby rest of the PCI was completed as any other conventional case.
In summary it is mandatory for an interventional cardiologist to keep in mind the anomalous origin and course of coronary artery during selection of PCI material and strategy as there is no standard technique to deal with such cases.
| References|| |
|1.||Engel HJ, Torres C, Page HL Jr. Major variations in anatomical origin of the coronary arteries: Angiographic observations in 4250 patients without associated congenital heart disease. Cathet Cardiovasc Diagn 1975;1:157-69. |
|2.||Kimbiris D, Iskandrian AS, Segal BL, Bemis CE. Anomalous aortic origin of coronary arteries. Circulation 1978;58:606-15. |
|3.||Yamanaka O, Hobbs RE. Coronary artery anomalies in 126595 patients undergoing coronary arteriography. Cathet-Cardiovasc Diagn 1990;21:28-40. |
|4.||Jim MH, Siu CW, Ho HH, Miu R, Lee SW. Anomalous origin of the right coronary artery from the left coronary sinus is associated with early development of coronary artery disease. J Invasive Cardiol 2004;16:466-8. |
|5.||Angelini P, Velasco JA, Flamm S. Coronary Anomalies: Incidence, pathophysiology and clinical relevance. Circulation 2002;105:2449-54 |
|6.||Topaz O, DiSciascio G, Goudreau E, Cowley MJ, Nath A, Kohli RS, et al. Coronary angioplasty of anomalous coronary arteries: Notes on technical aspects. Cathet Cardiovasc Diagn 1990;21:106-11. |
|7.||Oral D, Dagalp Z, Pamir G, Alpman A, Omurlu K, Erol C, et al. Percutaneous transluminal coronary angioplasty of anomalous coronary arteries. Case reports. Angiology 1996:47:77-82. |
|8.||Cohen MG, Toileson TR, Peter RH, Harrison JK, Sketch MH. Successful percutaneous coronary intervention with stent implantation in anomalous right coronary arteries arising from the left sinus of Valsalva: A report of two cases. Catheter Cardiovasc Interv 2002;55:105-8 |
|9.||Lee BI, Gist HC Jr, Morris EI. Percutaneous coronary artery stenting of an anomalous right coronary artery with high anterior take off using standard size 7 French left Judkins guiding catheters J Invasive Cardiol 2003;15:682-4. |
|10.||Yip H, Chen MC, Wu CJ, Yeh KH, Fu M, Hang CL, et al. Primary angioplasty in acute inferior myocardial infraction with anomalous origin right coronary arteries as infarct related arteries focus on anatomic and clinical features, outcomes, selection of guiding catheters and management. J Invasive Cardiol 2001;13:290-7. |
|11.||Qayyum U, Leya F, Steen L, Sochansk'i M, Grassman E, Cho L, et al. New catheter design for cannulation of the anomalous right coronary artery arising from the left sinus of valsalva. Catheter Cardiovasc Interv 2003;60:382-8. |
|12.||Rossen JD. Technical Note: A useful guide catheter modification for anomalous right coronary arteries. Catheter- Cardiovasc Interv 2005;65:37-40. |
|13.||Praharaj TM, Ray G. Percutaneous-transluminal coronary angioplasty with stenting of anomalous right coronary artery originating from left sinus of valsalva using the voda guiding catheter: A report of two cases. Indian Heart J 2001;53:79-82 |
|14.||Seth A. Understand and use your rights. Catheter Cardiovasc Interv 2005;65:41-2. |
[Figure 1], [Figure 2]