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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 122-124

Balloon-assisted guide catheter tracking: An innovative technique for anomalous right coronary artery stenting


Department of Cardiology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication12-Sep-2017

Correspondence Address:
K K Goyal
Department of Cardiology, Super-Specialty Block, Government Medical College, Kozhikode - 673 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_22_17

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  Abstract 

The most important factor for a successful percutaneous coronary intervention of an anomalous right coronary artery arising from left sinus is coaxial alignment of guide catheter and adequate backup support. In this report, we describe a novel case in which we used a distally parked balloon to assist in tracking and proper alignment of the guide catheter.

Keywords: Anomalous right coronary artery, coronary artery anomalies, percutaneous coronary intervention


How to cite this article:
Desabandhu V, Goyal K K, Shetty S. Balloon-assisted guide catheter tracking: An innovative technique for anomalous right coronary artery stenting. Heart India 2017;5:122-4

How to cite this URL:
Desabandhu V, Goyal K K, Shetty S. Balloon-assisted guide catheter tracking: An innovative technique for anomalous right coronary artery stenting. Heart India [serial online] 2017 [cited 2017 Oct 20];5:122-4. Available from: http://www.heartindia.net/text.asp?2017/5/3/122/214426


  Introduction Top


The incidence of coronary artery anomalies (CAA) ranges from 0.2% to 5.6% in various studies.[1],[2] Anomalous aortic origin of a coronary artery is a relatively common coronary anomaly of which anomalous origin of right coronary artery (RCA) is more frequent. Percutaneous coronary intervention (PCI) of an anomalous RCA from the left sinus of Valsalva is technically challenging as the anomalous origin impedes coaxial arrangement of guiding catheter and there is a lack of adequate backup force for the guiding catheter. We herein report a novel technique for PCI of an anomalous RCA in which we used a balloon to successfully track the guiding catheter and cannulate the RCA.


  Case Report Top


A 62-year-old hypertensive male was admitted with complaint of exertional angina Grade II to III for the last 1 month. He had a history of an inferior wall ST-elevation myocardial infarction 2 months back for which he was thrombolysed with streptokinase with fair ST resolution. The patient was taken for elective coronary angiography through the right femoral approach which showed an anomalous RCA arising from the left coronary sinus. The artery was hooked using a 7F Judkins left 3.5 diagnostic catheter and found to be having a mid-tubular tight lesion [Figure 1]. Left-sided coronary arteries were normal, and hence, it was decided to go ahead with an angioplasty of RCA. However, various attempts to cannulate RCA using 6F Judkins left 3.0, 7F Judkins left 3.5, 4.0 and Amlatz left AL1 were unsuccessful. We rehooked the RCA with 7FJL 3.5 diagnostic catheter, and a 300 cm long Fielder FC wire was passed. The diagnostic catheter was exchanged with a 7F JL 3.5 guide catheter but could not be hooked this time also. A 2 mm × 15 mm Ryujin plus balloon was passed distally in the RCA and dilated to 8 atm [Figure 2]. This anchoring force of the dilated balloon was utilized to lead the guide catheter and hence successfully hook the RCA. Once cannulated, the lesion was predilated using the same balloon at 12 atm [Figure 3]. Finally, RCA was stented in the mid part using 2.75 mm × 32 mm GenX Sync drug-eluting stent at 12 atm to a diameter of 2.91 mm and proximally using a 3 mm × 32 mm GenX Sync drug-eluting stent at 14 atm to a diameter of 3.20 mm. Final injection showed a TIMI III flow [Figure 4]. There was no dissection, thrombus, or any other periprocedural complication. The patient was discharged on the 2nd postoperative day and is awaiting routine follow-up after 1 month.
Figure 1: Anomalous right coronary artery arising from left coronary sinus showing a mid-tubular tight lesion

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Figure 2: A 2 mm × 15 mm Ryujin plus balloon placed distally in the right coronary artery and dilated to 8 atm

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Figure 3: The lesion being dilated at 12 atm after the right coronary artery is engaged coaxially

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Figure 4: Final injection showing TIMI III flow

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  Discussion Top


Congenital CAA are usually classified as abnormalities of origin and course, intrinsic anatomic abnormality, termination, and anomalous collateral vessels.[3] Among these, the prevalence of anomalous coronary arteries from opposite sinus varies from 0.1% to 0.3% in various studies.[4],[5] They are further classified depending on their course as interarterial, subpulmonic, prepulmonic, retroaortic, and retrocardiac. Among these subtypes, interarterial is usually associated with sudden cardiac death in young individuals whereas rest of the subtypes are generally considered benign and patients are frequently asymptomatic. Hence, it is not uncommon for patients with an anomalous RCA from left sinus to present for the first time with a coexistant atherosclerotic disease.

The ostium of anomalous RCA arising from the left sinus frequently lies anterior and cephalad to the left main coronary artery. The most frequently encountered problem while doing PCI for such arteries is the inability to coaxially align the guide catheter and lack of adequate backup support for the guide catheter. There are various case reports using different catheters for such cases. Multipurpose hockey stick catheter was used by Caliskan et al.[6] whereas Qayyum et al. reported the use of a modified AL catheter with a right-angled tip called the Leya catheter for cannulating and providing stable support for interventions on anomalous RCA.[7] However, these special catheters are not readily available in most of the catheterization laboratories. The authors described a case in which a primary PCI of anomalous RCA was done using a relatively shorter Judkins left guide and giving the wire a wider curve.[8] In the current case, we could hook the RCA ostium with a diagnostic catheter, but several attempts with different guide catheters were unsuccessful. Hence, a small balloon was parked distally into the RCA. The anchoring force of this dilated balloon helped in tracking and aligning the guide catheter coaxially following which the procedure was completed successfully.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Click RL, Holmes DR Jr., Vlietstra RE, Kosinski AS, Kronmal RA. Anomalous coronary arteries: Location, degree of atherosclerosis and effect on survival – A report from the Coronary Artery Surgery Study. J Am Coll Cardiol 1989;13:531-7.  Back to cited text no. 1
    
2.
Angelini P, Villason S, Chan AV Jr., Diez JG. Normal and anomalous coronary arteries in humans. Coronary Artery Anomalies: A Comprehensive Approach. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 27-150.  Back to cited text no. 2
    
3.
Angelini P. Coronary artery anomalies: An entity in search of an identity. Circulation 2007;115:1296-305.  Back to cited text no. 3
[PUBMED]    
4.
Pelliccia A, Spataro A, Maron BJ. Prospective echocardiographic screening for coronary artery anomalies in 1,360 elite competitive athletes. Am J Cardiol 1993;72:978-9.  Back to cited text no. 4
[PUBMED]    
5.
Zeppilli P, dello Russo A, Santini C, Palmieri V, Natale L, Giordano A, et al. In vivo detection of coronary artery anomalies in asymptomatic athletes by echocardiographic screening. Chest 1998;114:89-93.  Back to cited text no. 5
[PUBMED]    
6.
Caliskan M, Ciftçi O, Güllü H, Alpaslan M. Anomalous right coronary artery from the left sinus of Valsalva presenting a challenge for percutaneous coronary intervention. Turk Kardiyol Dern Ars 2009;37:44-7.  Back to cited text no. 6
    
7.
Qayyum U, Leya F, Steen L, Sochanski 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.  Back to cited text no. 7
[PUBMED]    
8.
Desabandhu V, Goyal KK, Thottian JJ, Rajasekharan S, Sajeev CG. Wiring from a distance-let's not waste time!!!. Kerala Heart J 2016;6:66-68.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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