The incidence of major anomalies of the coronary artery is 0.3–0.8% of the population undergoing coronary angiography.1 There are only a few cases in the literature describing successful percutaneous coronary intervention (PCI) to the anomalous coronary arteries from the femoral2 or brachial approaches.3 The transradial approach has been getting more and more popular because of its equal feasibility and less frequent bleeding complications compared with the femoral approach.4 Although one case with the anomalous right coronary artery lesion treated by transradial coronary intervention (TRI) has been reported,5 the feasibility of TRI in patients with anomalous origin of the left coronary artery has not been established. We report a case with the critical lesion in the left main coronary artery (LMCA), which anomalously originated from the right sinus of Valsalva, treated with the implantation of a self-expandable stent through the right transradial approach. Case Report. A 71-year-old woman was referred to our hospital because of progressive chest pain on effort. She had a history of transient cerebral ischemic attack 3 years prior. Her coronary risk factors included hypertension and hypercholesterolemia. No remarkable findings were observed on physical examination. Her 12-lead electrocardiogram and chest roentgenogram were normal. However, exercise stress test showed marked ST depression in leads V2 to V5 with prolonged chest pain. Coronary angiography was performed via the right brachial artery using a 5 French (Fr) multipurpose catheter (Medikit, Japan), and showed normal right coronary artery (RCA). However, the LMCA, which anomalously originated from the common ostium with the RCA in the right sinus of Valsalva, had a critical narrowing in the distal portion (Figure 1A). Left ventriculogram was normal. Contrast CT scan clearly demonstrated the anomalous LMCA running in front of the main pulmonary artery (Figure 2). The patient refused our strong recommendation for bypass surgery, and we decided to perform angioplasty on the LMCA lesion. Because we have experience with more than 5,000 cases of successful PCI through the right radial approach as a routine practice in our hospital and the anatomical relationship from the right subclavian artery to the anomalous LMCA was well documented at her diagnostic catheterization via the right brachial artery, we selected the right transradial approach for PCI. A 6 Fr introducer (Terumo, Tokyo, Japan) was inserted into the right radial artery. Because the attempt to engage the LMCA by using a 6 Fr, Zuma2 multipurpose guiding catheter (Medtronic AVE, Santa Rosa, California) failed, we changed to the left Amplatz 0.75 (AL-0.75) Zuma2 guiding catheter. While keeping the tip of the AL-0.75 guiding catheter a little bit out from the ostium by pushing a dummy H/T Balance guidewire (Guidant Corporation, Temecula, California), which was deeply inserted into RCA, we could successfully cross the lesion in the distal LMCA by the second H/T Balance guidewire (Figure 1B). The lesion was successfully dilated using a 2 mm Aerocross balloon (Kaneka) at 12 atmospheres (Figure 1C). Six months later, angina recurred. Coronary angiography through the right radial approach showed a new severe narrowing in the proximal LMCA and restenosis in the distal LMCA (Figure 3A). With the same technique as the first angioplasty, the lesions in the LMCA were successfully crossed by a H/T Balance guidewire with the assistance of a dummy guidewire in the RCA using a 6 Fr AL-0.75 guiding catheter. The restenotic lesion was smoothly dilated with the inflation of a 2.5 mm balloon (Aerocross) at 10 atmospheres. After dilatation of the proximal lesion by the same balloon at 10 atmospheres, severe dissection was observed. Since we thought that any balloon-expandable stents could not reach the dissected part because of the severe tortuosity and inadequate fixation of the guiding catheter into the LMCA, we used a self-expandable, 3.0 x 30 mm RADIUS stent (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) to treat this dissection. The stent reached the dissected portion and was successfully expanded there (Figure 3B). The stent was post-dilated using a 2.75 mm LTX-2 balloon (Medtronic AVE) at 8 atmospheres (Figure 3C). She was discharged the next day. During the 1-year clinical follow-up period, she had no chest pain or clinical events. Discussion. The incidence of anomalous LMCA originating from the right sinus of Valsalva is very low; it is found in 0.017% of all selective coronary angiography cases and 1.3% of patients with anomalous coronary anatomy.6 The clinical significance of the anomalous LMCA originating from the right sinus of Valsalva depends on its relationship with the aorta and main pulmonary artery. If the anomalous artery runs between these two great vessels, it is frequently associated with anginal or syncopal attacks, or even with sudden death.6 However, when the artery runs in front of the main pulmonary artery, as seen in this case, it is rarely associated with these complications.7 Angioplasty for the anomalous coronary arteries is technically challenging, since all of the guiding catheters are designed for the normal coronary anatomy. An anomalous left coronary artery usually originates from the right sinus of Valsalva near the ostium of the RCA, so that the multipurpose catheter is helpful for selective cannulation.8 However, because the handling of the guiding catheters is more difficult than the diagnostic catheters, we could not engage the multipurpose guiding catheter into the anomalous artery. In this situation, a left Amplatz guiding catheter is helpful.9 Because left Amplatz guiding can easily face against the RCA, it is theoretically expected to provide good back-up support against the anomalous LMCA originating near the ostium of RCA. The direct insertion of the guidewire into the anomalous artery was not successful in this case because of the common ostium of the anomalous LMCA and the RCA. In this situation, a dummy guidewire technique is helpful.10 We put a dummy guidewire deeply into the RCA, so that the guidewire pushed away and fixed the tip of the guiding catheter. At that point, we could easily pass the second guidewire into the anomalous artery. Transradial coronary intervention is popular in Japan. It can reduce bleeding complications and increase patient comfort. In our hospital, we are using this approach in almost 80% of patients who undergo angioplasty with good clinical outcomes.4 The radial approach might be better than the femoral approach in angioplasty for the anomalous coronary arteries, since it can provide a different anatomical relationship between the guiding catheters and the coronary sinuses.5 The self-expandable RADIUS stent has an advantage compared to balloon-expandable stents in successful stent deployment. Its stent delivery system is sheath-protected, so that it is theoretically rare to lose the stent before the system reaches the lesions. Hirayama et al. reported a high delivery success rate for the RADIUS stent without any stent migration, even in calcified coronary arteries.11 A recent randomized trial comparing it with the balloon-expandable Palmaz-Schatz stent showed its higher success rates in stent delivery and procedures.12 The RADIUS stent is one of the best stents for these anomalous and tortuous coronary arteries as in this case. In conclusion, this is the first report in the literature of a patient who could be successfully treated using self-expandable RADIUS stent implantation through the right radial approach for the significant narrowing in the tortuous and anomalous LMCA originating from the right sinus of Valsalva.
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