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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 28-32

A case of non-ST elevation myocardial infarction presenting with Shepherd's crook right coronary artery with tortuosity: Issues in management


Department of Cardiology, Heritage Hospital, Varanasi, Uttar Pradesh, India

Date of Web Publication27-Apr-2018

Correspondence Address:
Alok Kumar Singh
Department of Cardiology, Heritage Hospital, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_13_18

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  Abstract 


Shepherd's Crook (UPSL0PING) right coronary artery (RCA) is a special situation where RCA origin is not only superiorly oriented but also courses superiorly to some extent before making a U-turn. Presence of Shepherd's Crook RCA along with tortuosity in coronary artery makes the angioplasty very much technically demanding. Here I am reporting a case of Non-ST segment elevation myocardial infarction presented with 99% thrombus containing lesion in tortuous and Shepherd's Crook RCA successfully managed with angioplasty.

Keywords: Non ST elevation myocardial infarction (NSTEMI), right coronary artery (RCA), Shepherd's Crook


How to cite this article:
Singh AK. A case of non-ST elevation myocardial infarction presenting with Shepherd's crook right coronary artery with tortuosity: Issues in management. Heart India 2018;6:28-32

How to cite this URL:
Singh AK. A case of non-ST elevation myocardial infarction presenting with Shepherd's crook right coronary artery with tortuosity: Issues in management. Heart India [serial online] 2018 [cited 2018 Sep 23];6:28-32. Available from: http://www.heartindia.net/text.asp?2018/6/1/28/231341




  Introduction Top


Shepherd's crook (UPSL0PING) right coronary artery (RCA) is a special situation where RCA origin is not only superiorly oriented but also courses superiorly to some extent before making a U-turn. Presence of stenosis distal to tortuosity along with Shepherd's crook RCA makes the angioplasty extremely challenging. Here, I am reporting a case of Non-ST segment elevation myocardial infarction presented with 99% thrombus containing lesion successfully managed with angioplasty.


  Case Report Top


A 45-year-old male admitted with the history of severe rest chest pain for 2 days. His echocardiogram (ECG) was apparently normal and ECG shows the mild hypokinesia of RCA distribution. His troponin I was elevated (4.8 ng/ml reference <0.001 ng/ml). Hence, the working diagnosis of non-ST segment elevation myocardial infarction was made. Patient was given the loading dose of 600 mg clopidogrel, disprin 325 mg, and atorvastatin 80 mg. His angiogram was done through right femoral route which shows normal left coronary system and in RCA shows mid 99% thrombus containing lesion [Figure 1] and [Figure 2]. RCA was Shepherd's crook at its origin and there were 390° bend in RCA proximal to target lesion. Due to tortuosity and Shepherd's crook origin, angioplasty of this lesion is very much technically demanding. In view of persistent angina, we proceeded with the planning of angioplasty of this lesion. In view of its upward origin, I decided to take the Amplatz L-2 guide catheter which gives the good coaxial support in this case. After hooking the RCA with AL-2, I took Whisper extra support wire for wiring the lesion and by making three curves in wire with very much difficulty I could wire the lesion after several failed attempts. Real reason in difficulty in wiring this case, which I encountered, was when wire crosses two initial bends the curve of wire used to get straightened and used to enter in the right ventricular branch but somehow after multiple failed attempts I could cross the lesion and park the wire in distal posterolateral branch of RCA. Lesion was predilated with the balloon of 2 mm × 10 mm at 16 atm. Afterward I took the endeavor resolute, 2.75 mm × 24 mm across [Figure 3] the lesion and implanted at 14 atm. After stent implantation in check angio, I observed the slow flow in distal RCA in the left anterior oblique view then I took the second angio in the right anterior oblique view which shows spiral dissection starting from proximal RCA to distal RCA [Figure 4] and [Figure 5] posterior to stent itself. Afterward I reviewed the previous angio, then I could see during passing of stent in RCA AL-2 guide catheter was jumped into proximal RCA which may have caused the proximal dissection in RCA, which extended beyond the lesion in distal RCA extending up to PDA. As soon as I realized the dissection started in proximal RCA, I took another long stent endeavor resolute, 3 mm × 30 mm in proximal RCA [Figure 6] implanted at 16 atm and then I took another long stent implanted in distal stent [Figure 7] overlapping with first stent then whole lesion was postdilated with 3 mm × 12 mm at 16 atm. In final angiogram, RCA with distal TIMI III flow was present [Figure 8]. He remains asymptomatic in 5-month follow-up. Follow-up coronary angiogram after 5 months shows patent stent [Figure 9] and [Figure 10].
Figure 1: Tortuous right coronary artery showing mid 99% stenosis

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Figure 2: RAO view showing mid right coronary artery 99% stenosis

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Figure 3: Stent implanted in mid-right coronary artery

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Figure 4: Poststent implantation dissection in proximal right coronary artery (RAO view)

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Figure 5: Poststent implantation dissection in proximal right coronary artery (LAO view)

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Figure 6: Stent implanted in proximal right coronary artery

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Figure 7: Stent implanted in distal right coronary artery

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Figure 8: Postpercutaneous coronary intervention final result (RAO view)

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Figure 9: Postpercutaneous coronary intervention final result (LAO view)

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Figure 10: Postpercutaneous coronary intervention 5-month follow-up angio showing patent stents

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  Discussion Top


Shepherd's crook (UPSL0PING) RCA is a special situation where RCA origin is not only superiorly oriented but also courses superiorly to some extent before making a U-turn. Percutaneous transluminal coronary angioplasty (PTCA) of lesions in a RCA with a “Shepherd's crook” configuration may pose procedural challenge because here we do not need only coaxial support from catheter but it should provide enough support to guide wire and other devices which have to make a 180° turnaround.[1] Judkins right catheter does not give enough support in case of shepherd's crook RCA. The Amplatz left catheters provide great passive backup support and is the choice of catheter in complex coronary intervention (i.e., chronic total occlusion, tortuous arteries, calcified lesion). Amplatz catheter provides passive backup support from the contralateral sinus of Valsalva and deep seated in ostium. AL catheters are known to cause dissection because they tend to prolapsed when we pull it, so utmost care is required during the use of these catheters. Coaxial alignment of AL catheters strictly should be maintained to avoid dissection which may be catastrophic if not promptly recognized and treated. Selection of guiding catheter depends on the orientation and origin of coronary vessel. For LAD interventions XB, or XB LAD is chosen, whereas a Voda or EBU catheter may be appropriate for the LCX interventions. In RCA, JR catheters are workhorse catheter for percutaneous coronary intervention (PCI), whereas in the presence of tortuosity and upsloping RCA, AL catheters are the choice. In downsloping RCA, multipurpose catheters usually give better support.

Tortuosity may be defined as at least 2 or more than 75° bend proximal to the target lesion or at least one proximal bend 90°. As in our case, there were three bends of 90° before lesion makes this case very challenging. PCI of these lesions is associated with a lower success rate (70%–85%) and higher acute complications (up to 15%).[2],[3] Proper selection of hardware, guide catheters, guide wire, and balloon catheter is critical for success and safety of these procedures. In reference to index case, presence of shepherd's crook RCA with extreme tortuosity make this lesion extremely difficult. The prerequisites for guide catheter are better support, perfect coaxiality, kink resistance, and the ability to fix the tip of catheter in ostium of intubated artery contributing to a stable position. By keeping above facts in mind, I used AL-2 catheter in this case. As per the ACC/AHA classification of coronary artery lesion [Table 1], this case had two characteristics of Type C lesion such as excessive tortuosity of proximal segment as well as extremely angulated segments (>90°). The initially expected wide range of performance in lesions of differing complexity, as predicted by the original 1988 classification,[4] has been improved substantially over the years due to improved technology such as stents, better wires, and better operator skills. Later on, the data from the society of coronary angiography and interventions registry (SCAI), collected in more than 40,000 single-vessel interventions performed from 1993 to 1996, were used to evaluate the predictive ability of the ACC/AHA lesion classification system and to determine if an improved predictive model could be developed.[5] The SCAI simplified classification scheme is superior as a predictive model of coronary intervention than the AHA/ACC classification system and is a powerful tool in predicting procedural success and complication. Even with SCAI simplified classification, this case lesion will be classified as Type C patent, in which overall procedural success will be 90% in comparison to Type A and B lesion, where the procedural success is 97.2% and 96.5%, respectively. Hence, in dealing such type of cases, meticulous planning is necessary to get good procedural success and avoid complication.
Table 1: American College of Cardiology/American Heart Association classification of coronary lesion

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nesto RW, Sassower MA. PTCA of “shepherd's crook” right coronary arteries with a new shape of guiding catheter. Cathet Cardiovasc Diagn 1993;29:70-3.  Back to cited text no. 1
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2.
Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morphologic determinants of coronary angioplasty success and complications: Current experience. J Am Coll Cardiol 1995;25:855-65.  Back to cited text no. 2
[PUBMED]    
3.
Ellis SG, Vandormael MG, Cowley MJ, DiSciascio G, Deligonul U, Topol EJ, et al. Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel angioplasty prognosis study group. Circulation 1990;82:1193-202.  Back to cited text no. 3
    
4.
Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB 3rd, Loop FD, et al. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988;78:486-502.  Back to cited text no. 4
[PUBMED]    
5.
Krone RJ, Laskey WK, Johnson C, Kimmel SE, Klein LW, Weiner BH, et al. A simplified lesion classification for predicting success and complications of coronary angioplasty. Registry Committee of the Society for Cardiac Angiography and Intervention. Am J Cardiol 2000;85:1179-84.  Back to cited text no. 5
[PUBMED]    


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