Coronary Cannulation Through Mirror-Image Right Aortic Arch During Right Transradial Approach: A Rare Case Report With Review of Literature

Volume 24 - Issue 5 - May 2012
Posted on: 4/27/12
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Author(s):

Tejas Patel, MD^1,2, Sanjay Shah, MD^1,2, Samir Pancholy, MD³

Abstract: Although right aortic arch (RAA) is a rare developmental anomaly, it can create a challenging anatomical situation while cannulating coronaries working through right transradial approach (TRA). We describe a rare adult patient with mirror-image RAA, whose coronary angiogram was performed through right TRA. We have also discussed the challenges encountered because of RAA and technique to enter the ascending aorta.

J INVASIVE CARDIOL 2012;24(5):234-235

Key words: transradial approach, right aortic arch, coronary cannulation

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Case Report

A 58-year-old male patient with history of diabetes (10 years) and hypertension (15 years) was admitted for coronary angiography. He gave history of effort angina and positive stress test. Patient was prepared for coronary angiogram through right transradial approach (TRA). Radial artery puncture was done and a 5 Fr Radifocus introducer sheath (Terumo) was deployed using standard technique. A 5 Fr Optitorque Tig catheter (Terumo) was introduced with a 0.032˝ standard exchange-length guidewire.

In this patient, the catheter had a tendency to dive repeatedly into the descending thoracic aorta, maintaining right paraspinal position (Figure 1A). It was initially misinterpreted as entry into the right atrium through the superior vena cava. However, pressure tracing was suggestive of arterial pressure. Angiogram with pigtail catheter was done to define anatomy, and confirmed the right paraspinal position of the descending thoracic aorta (Figure 1B). Another angiogram in aortic arch position confirmed innominate artery origin at an acute angle from right aortic arch (RAA; Figure 1C). Keeping curvilinear calcification as a roadmap, the ascending aorta was entered with some difficulty (Figures 1D and 1E). Aortic root angiogram showed a faintly opacified right coronary artery (RCA) that was nondominant and normal (Figure 1F). Selective left coronary artery (LCA) injection was performed after exchanging the Pigtail catheter to a 5 Fr Optitorque Tig catheter (Figure 1G).