Use of GuideLiner to Facilitate Percutaneous Coronary Intervention in Three Patients With Anomalous Right Coronary Artery Arising from the Left Coronary Sinus

Abstract

An anomalous right coronary artery (RCA) is a rare congenital anomaly that poses challenges to the interventional cardiologist when the culprit lesion is located in the anomalous vessel. Locating and selective engagement of the anomalous RCA at the time of diagnostic coronary angiography can be difficult in spite of the availability of a wide range of guide catheters of different shapes and curves. CT coronary angiography before invasive angiography can be very helpful in demonstrating the location of the anomalous vessel to the interventional cardiologist, and obviate the need for selective angiography should it be free of disease, potentially reducing procedure time and radiation dose. We report our experience on PCI of 3 patients with culprit lesions in anomalous RCAs originating anterior to the left coronary sinus, with the use of short, secondary curve Judkin’s left coronary guide catheters and the GuideLiner.

Anomalous origin of the right coronary artery (RCA) arising from the left coronary sinus is a rare congenital anomaly. In a large series of 126,595 consecutive diagnostic coronary angiograms between 1960-1988, this was found in 135 cases (0.11%).¹ Another 59 cases were found on medical literature review.^2-12 This coronary anomaly is a significant challenge for the interventional cardiologist, especially if the culprit lesion is in the anomalous vessel, not only with respect to imaging, but also coronary intervention. Selecting a coronary guide catheter with the suitable curve to engage the anomalous vessel can be difficult, because of variations in the actual location of the RCA ostium^5,6,10-12, although it is usually located close to the left coronary sinus. The availability of the GuideLiner catheter in the last few years may facilitate selective engagement and intervention in anomalous RCAs.^13,14 We report our experience on successful percutaneous coronary intervention (PCI) with the use of the GuideLiner (Vascular Solutions) in three patients presenting with angina whose culprit lesions were located in the RCA with this anomaly. 

Case Reports

Case 1. A 62-year-old Canadian man with a history of diabetes, hypertension, dyslipidemia, and a current history of smoking presented with chest pain and troponin I 0.8, but no electrocardiogram (ECG) changes. Coronary angiography via the right radial approach revealed no significant disease in the left coronary artery, but at least moderate disease in an anomalous RCA arising from the left coronary sinus anterior to the left coronary artery takeoff (Figure 1A), which could not be engaged selectively, despite trying different pre-shaped catheters, including a 6 French (Fr) Judkins Right (JR)⁴, modified Amplatz Right (AR), Amplatz Left (AL)1, AL 0.75, multipurpose and Judkins Left (JL) 3.5 catheters. After case review by the interventional cardiologist group, it was decided to use a right femoral approach for PCI in a second procedure. Selective engagement of the anomalous RCA was unsuccessful with JR, Extra Support (XB), AR and AL catheters. Finally, a JL 3.5 guide catheter positioned just below the left coronary artery origin enabled a Runthrough wire (Terumo) to be directed into the anomalous RCA, following which a GuideLiner was introduced over the wire to selectively engage the RCA ostium. Excellent angiographic images of the anomalous RCA could then be obtained, showing severe mid-RCA stenosis. The culprit lesion was dilated and stented with excellent final result (Figure 1B). The procedure time from use of JL 3.5 guide catheter for RCA PCI to completion of procedure with GuideLiner support was 51 minutes.

Case 2. A 62-year-old Chinese man with no coronary risk factors presented with angina and a positive stress test. As the patient preferred non-invasive imaging assessment, computed tomography (CT) coronary angiography was done, which showed a moderate to severe lesion in the mid-segment of the RCA that had an anomalous origin anterior to the left coronary sinus. The patient then agreed to coronary angiography. This was initially performed via the left radial approach but the anomalous RCA could not be selectively engaged. Femoral arterial access was then used. The anomalous RCA was faintly visualized using a 6 Fr JL 3.0 guide catheter. Other coronary guide catheters, including a 6 Fr JL 3.5, JL 4.0, 5 Fr multipurpose, and 5 Fr AL1 catheters all failed to engage the anomalous RCA. The 6 Fr JL 3.0 guide catheter was then re-introduced and positioned just below the anomalous RCA ostium. A Runthrough wire could then be directed into the anomalous RCA. This was exchanged, using a Finecross microcatheter (Terumo), for an Iron Man wire (Abbott Vascular), over which a GuideLiner was advanced to engage the RCA ostium. Coronary angiography revealed 80% proximal stenosis and 80% stenosis in the posterolateral branch (Figure 2A). Both lesions were dilated and stented with an excellent final result (Figure 2B). Procedure time from use of a JL 3.0 guide catheter for RCA PCI to completion of procedure with GuideLiner support was 81 minutes.

Case 3. A 66-year-old Chinese man with hypertension and dyslipidemia presented with angina and a positive stress test. Again, as per patient preference, CT coronary angiography was performed, and showed significant proximal and mid-segment disease in an anomalous RCA with origin anterior to the left coronary sinus. Coronary angiography via the right femoral approach with 6 Fr JL 4, JL 3.5, JL 3.0, 5 Fr multipurpose, and AL1 guide catheters failed to selectively engage the anomalous artery. The 6 Fr JL 3.0 catheter was then tried again and positioned anterior to the left coronary artery and just below the RCA ostium. A Sion Blue wire (Asahi Intecc) could then be introduced into the RCA, over which a GuideLiner catheter was advanced to engage the anomalous RCA ostium. Coronary angiography revealed 90% proximal and 90% mid-segment stenosis in the anomalous RCA (Figure 3A). Both lesions were dilated and stented with excellent final result (Figure 3B). Procedure time from the use of JL 3.0 guide catheter for RCA PCI to completion of procedure with GuideLiner support was 59 minutes.

Discussion

An anomalous RCA arising from the left coronary sinus is a rare congenital condition.¹ Much as the anomalous artery may course between the aorta and the pulmonary artery, the risk of sudden cardiac death did not appear to be increased.^1,2,4,10 Even in patients with this congenital anomaly with angina, most reported cases have coronary atherosclerosis rather than ostial compression as a cause of their symptoms.^5,7,9,13,14 

In this case series, the first patient was from Canada and the other two from Hong Kong, where patients prefer non-invasive investigations. The coronary anomaly was already known in two patients who had CT coronary angiography prior to catheter-based coronary angiography. The anomalous RCA in all 3 patients arose anterior to the left coronary sinus. Even with this information, selective engagement of the anomalous RCA was still difficult and not easily achieved, despite attempts with a wide range of pre-shaped coronary catheters. However, CT coronary angiography probably still reduced the total amount of radiation, contrast used and procedure time. Instead of not finding the right coronary artery in its usual position and then searching for it with an aortogram or exploratory injections with different catheters, the cardiologist can focus on engaging the anomalous coronary artery from the start of the procedure. In patients with no disease in the anomalous vessel, CT coronary angiogram can also be very helpful in negating the need for selective anomalous RCA angiography.

Multiple coronary guide catheters of different shape and curve configurations were tried in each patient without much success in selective engagement of the anomalous RCA. However, by using a femoral approach and Judkins left coronary catheters with shorter (3-3.5 cm) secondary curves advanced against the posterior wall of the aortic root to slightly “retroflex” the tip anteriorly towards the anomalous RCA ostium, it was possible to direct a PCI wire into the anomalous RCA from close proximity. Once the wire was advanced into the mid-distal RCA, a GuideLiner could then be introduced over the wire to engage the RCA ostium for selective angiography, as well as performance of PCI of lesions in the anomalous vessel, with procedure times very comparable to usual PCI procedures. In Case 2, even stenting of a severe lesion in the posterolateral branch of the distal RCA was easily accomplished without guide catheter support problems. 

Conclusion

The GuideLiner is a very useful adjunct in PCI in this case series of anomalous RCAs that originate anterior to the left coronary sinus, when used in conjunction with Judkins left coronary guide catheters with short secondary curves. It provides selective engagement and excellent backup support for imaging and PCI. CT coronary angiography may be particularly helpful in these rare cases of anomalous coronary arteries, as it helps to determine the access approach and the choice of guide catheters if the disease is in the anomalous vessel, and obviates the need to engage and image the anomalous vessel should it be free of significant disease. In this case series of anomalous RCA PCIs, the use of CT coronary angiography and the GuideLiner not only contributed significantly to the success of the procedures, but potentially also reduced procedure time, contrast dose, and radiation exposure.

References

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¹C.K. Hui Heart Centre, Royal Alexandra Hospital, Edmonton, Alberta, Canada; ²Sir Run Run Shaw Heart Centre, St. Teresa’s Hospital, Kowloon, Hong Kong

Disclosure: Dr. William K. K. Hui and Dr. C. M. Wong report no conflicts of interest regarding the content herein. 

Corresponding author: William K. K. Hui, MBBS, FRCP(C), FRCP(Edin), FACC, FHKAM, FHKCP, C.K. Hui Heart Centre, Royal Alexandra Hospital, 10240 Kingsway Ave, Edmonton, Alberta, Canada T5H 3V9. Tel: +1-780-735-5962. 
Email: whui@ualberta.ca