Visualization of a Rare Coronary Anomaly via the Transradial Approach

Introduction

Congenital coronary anomalies are rare in clinical practice, and can be difficult to properly engage and adequately visualize on coronary angiography. Herein, we present a case of a single coronary artery arising from the right coronary cusp and selective engagement of each coronary artery with the use of a single diagnostic catheter via the transradial approach. 

Case report

A 57-year-old man with a past medical history of chronic inflammatory polyneuropathy presented to his cardiologist’s office with chest pain and shortness of breath on exertion, and was referred for a coronary angiogram. After initial access of the right radial artery with a 21-gauge Jelco angiocatheter using a double-wall puncture technique, a .021-inch guide wire was inserted into the radial artery, followed by a 5 French (Fr) Glidesheath (Terumo). An Infiniti RBL (radial bilateral) diagnostic catheter (Cordis) (Figure 1) was utilized for the angiogram. The catheter was advanced into the right coronary cusp. When normal engagement of the right coronary was not achieved, a small, nonselective injection of contrast into the cusp was performed. This test injection revealed the coronary ostium to be positioned superior and anterior to its normal location. By slowly pulling up the catheter with a slight anterior motion, we were able to engage the coronary artery. Angiography demonstrated a single coronary ostium with visualization of the left anterior descending artery (LAD), left circumflex (LCx), and right coronary artery (RCA) all arising from the right cusp (Figure 2). Using the same catheter, each coronary artery was directly engaged individually (Figures 3-5). A non-selective contrast injection into the left coronary cusp did not reveal evidence of other coronary arteries. No catheter exchange was necessary and a minimal amount of contrast was used. The angiogram revealed non-obstructive coronary artery disease in all three vessels.

Discussion

Congenital coronary anomalies are relatively rare, with an incidence of 0.9-1.3% in all patients undergoing cardiac catheterization.¹ Separate ostia of the LAD and the LCx was the most common anomaly, followed by the LCx arising from the RCA, and then the RCA arising from the left coronary cusp. The anomaly seen in this case, a single coronary artery, has an incidence of 0.02% (about 1.3% of all anomalies found during cardiac catheterization).^1-3

Congenital coronary anomalies are sometimes difficult to engage and adequately visualize, thereby requiring the use of multiple diagnostic catheters, resulting in increased procedure and fluoroscopic time, as well as contrast use. The transradial approach, while lowering the rate of major access site complications and allowing earlier patient ambulation in comparison to the transfemoral approach⁴, may present an added challenge in anomalous coronary artery cases, since new operators may not be as familiar with specific techniques and optimal catheter selection. However, as seen in this case, the correct technique and catheter selection in challenging cases of anomalous coronary arteries can make a transradial approach feasible. 

While the coronary angiogram did not show obstructive disease in this patient, it is still important to decipher the course of the anomalous vessels to ensure that they do not run between the aorta and pulmonary artery, which can cause chest pain from constriction during systole.  Multiple projections, including right anterior oblique and lateral projections, were inconclusive, so cardiac computed tomography angiography should be performed to rule out a malignant course. In general, patients with an anomalous coronary artery arising from the opposite cusp along with a course between the aorta and pulmonary artery are at a higher risk for sudden death, and surgical management should be considered.⁵ Finally, in the case discussed herein, after ruling out a malignant course of the anomalous vessel, the patient was treated for non-cardiac causes of his chest pain, likely a manifestation of his known chronic inflammatory polyneuropathy.

Disclosure: The authors report no conflicts of interest regarding the content herein.

This article received a double-blind peer review from members of the Cath Lab Digest Editorial Board.

The authors can be contacted via Supreeti Behuria, MD, at sbehuria@chpnet.org

References

1. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990; 21: 28.
2. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation. 2002; 105: 2449-2454.
3.  Barriales-Villa R, Moris C, Sanmartin JC, et al. [Anomalous coronary arteries originating in the contralateral sinus of Valsalva: Registry of thirteen Spanish hospitals (RACES)]. Rev Esp Cardiol. 2006; 59: 620-623.
4. Agostoni P, Biondi-Zoccai GL, Benedictis LD, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures. J Am Coll Cardiol. 2004; 44(2): 349-354.
5. Angelini P. Congenital heart disease for the adult cardiologist: coronary artery anomalies. Circulation. 2007; 115: 1296-1305.