ABSTRACT: Percutaneous coronary intervention (PCI) in an anomalous right coronary artery (RCA) arising from the left sinus of Valsalva can be technically difficult because selective cannulation of the vessel may not be easy. We present a case of two consecutive successful stent implantations in an anomalous RCA arising from the posterior left sinus of Valsalva. We used a Judkins left 5 guiding catheter, which provided excellent angiographic visualization and guide support for stent delivery throughout the procedure.
J INVASIVE CARDIOL 2010;22:E175–E176
An anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva is a congenital abnormality with an incidence of 0.1% in patients studied angiographically.1 It is also known that an anomalous origin of the RCA can lead to angina pectoris, myocardial infarction (MI) or sudden death in the absence of atherosclerosis.2 We present this case because percutaneous coronary intervention (PCI) of such an exceedingly rare coronary anomaly is rarely described. Case Report. A 61-year-old female with a history of coronary artery bypass grafting 5 years previously (left anterior descending artery to the left internal mammary artery only), hypertension, dyslipidemia and hypothyroidism presented to the emergency department with substernal chest pain on rest. Her electrocardiogram revealed sinus rhythm with a rate of 52 bpm with pathological Q-waves in the aVF lead, and biphasic T-waves in the leads D1 and aVL and showed left-axis deviation. With the diagnosis of unstable angina, cardiac catheterization was performed with access through the left radial artery. The left coronary artery was cannulated with a Judkins left 4 (JL4) diagnostic catheter. Nonselective injection of the ascending aorta revealed an aberrant origin of the RCA from the posterior part of the left sinus of Valsalva. At the first attempt, a JL4 was tried, but it was observed to be too short to engage the ostium. Then, a JL5 diagnostic catheter was used to engage the aberrant RCA selectively without any difficulty. Subsequent angiography revealed an 80% diffuse lesion in the proximal vessel, and a 90% discrete, eccentric lesion in the middle portions of the artery (Figure 1). Subsequently, PCI was performed with the same JL5 guiding catheter (Figure 2), which provided an excellent support and visualization of the RCA. Both lesions were easily crossed with a floppy guidewire and were predilated with a 2.5 x 20 mm Troya balloon catheter (Nemed, Turkey) at 12 atm. The distal lesion was treated with implantation of a 2.75 x 18 mm Liberté coronary stent (Boston Scientific Corp., Natick, Massachusetts) delivered at 14 atm. The proximal lesion was stented with a 3.5 x 28 mm Liberté coronary stent at 12 atm. The final angiogram revealed an excellent result (Figure 3). Medical treatment included a daily regimen of aspirin 300 mg, clopidogrel 75 mg, carvedilol 25 mg, atorvastatin 20 mg and cilazapril 5 mg plus hydrochlorothiazide 12.5 mg. The patient had an uneventful hospital course and was discharged on the following day. On the third month of follow up, she was completely well without any discomfort. Discussion. The selective cannulation of aberrant coronary arteries can be technically difficult and time-consuming. Knowledge of the variations in coronary artery origin can help greatly in selecting the appropriate catheters for diagnostic and therapeutic interventions.3 Specifically, an anomalous origin of the RCA from the left sinus of Valsalva is very rare and has been noted in 0.02–0.17% of coronary arteriograms.4 The artery most commonly lies anterior and cephalad to the left main coronary artery. It typically takes an abrupt caudal and rightward course anterior to the aorta, between the great vessels, prior to continuing on into the right-sided atrioventricular groove. In our case, the RCA was posteriorly located. If an anomalous origin of the RCA from the left sinus of Valsalva is found in a young individual with exertional chest pain or syncope or provocable inferior ischemia, surgical correction of this anomaly must be strongly considered. This anomaly has been found in some necropsy studies of individuals with sudden unexplained death.5 When this anomaly is encountered in an adult with coexistent atherosclerotic coronary disease, percutaneous intervention may present a challenge. The anterior location of the ostium in the left sinus, the tortuous proximal portion and the initial anterior-caudal and rightward course all present challenges for coronary cannulation and, more importantly, backup support during PCI. There are a small number of single case reports of coronary interventions in anomalous RCAs originating from the left sinus of valsalva.6–13 Most of these reports describe the experience with balloon angioplasty alone using 8 Fr guiding catheters of different configurations. The Amplatz AL-1 guiding catheter has been successfully used in 3 cases.6–8 In 2 of these cases, a balloon-on-a-wire system had to be used to treat the target lesion because of poor guide catheter support. In another case reported by Oral et al,9 stable support could not be accomplished with the use of an Amplatz AL-2 guiding catheter, and they were unable to advance a balloon catheter into the anomalous coronary artery. Other investigators have used guiding catheters with shapes similar to the Judkins left catheter, but with small secondary curves (JL 3.5 and 4).10–12 On the other hand, our case was performed with a technique that utilized a JL5 guiding catheter which had a relatively big secondary curve and provided excellent backup support for delivery of the angioplasty balloon and stent. We think that choosing a left Judkins catheter with a greater curve could provide much more backup for intervention than a smaller curve, as it sits more on the non-coronary cusp after engagement of aberrant artery. Successful PCI of anomalous coronary arteries greatly relies on optimal guiding catheter seating and backup support. While each individual case may require a slightly different approach, we believe that the method described here for cannulation of an aberrant RCA arising from the left sinus of Valsalva will increase the likelihood of technical success in the majority of cases.
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From Ankara University, School of Medicine, Cardiology Department, Ankara, Turkey. The authors report no conflicts of interest regarding the content herein. Manuscript submitted January 13, 2010 and accepted January 25, 2010. Address for correspondence: Basar Candemir, MD, Ibni Sina Hastanesi, Kardiyoloji AD, Sihhiye, Ankara 06600 Turkey. E-mail: Basarcandemir@yahoo.com