Percutaneous Coronary Intervention of a Totally Occluded Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva

Coronary arterial anomalies occur in approximately 1% of the population, without other congenital cardiac malformations.¹ The incidence of anomalous origin of the right coronary artery out of the right sinus of Valsalva ranges from under 0.01–0.09%. It usually arises from the left sinus of Valsalva or the ascending aorta above it, and in most reported cases, it courses between the great vessels. Rarely, the anomalous origin is found to be from the posterior sinus or another coronary artery. If the anomalous vessel has significant atherosclerotic disease requiring percutaneous coronary intervention (PCI), the cannulation procedure becomes even more demanding. Proper selection of a guiding catheter is essential to successful angioplasty of anomalously arising coronary arteries.^3–7

Case Report. A 47-year-old male with a history of hypertension and dislipidemia suffered an inferior ST-elevation myocardial infarction (MI) for which he received thrombolytic therapy. Ten days later, he underwent elective coronary angiography in our catheterization laboratory. The left coronary artery had no critical stenosis (Figure 1). An anomalous RCA arising from the left sinus of Valsalva was totally occluded in its mid segment (Figure 2). The anomalous RCA was well visualized with an Amplatz Left II catheter (Figure 3). Coronary angioplasty was performed using a 7 Fr Amplatz Left II guiding catheter and 0.014 inch PT2 guidewire. There was difficulty in crossing the total occlusion, thus we inflated a Maverick 1.5 x 15 mm balloon (Boston Scientific Corp., Natick, Massachusetts) at 12 atm for better support. After the advance of the guidewire at the distal vessel, multiple inflations of a Maverick 2.0 x 15 mm balloon were performed (up to 18 atm). Distally, the vessel had diffuse disease, therefore it was necessary to perform reconstruction of the vessel with the implantation of 4 Taxus-Liberté stents (Boston Scientific) (total stented length, 92 mm). The stents were dilated with a Quantum 3.0 x 15 mm balloon (Boston Scientific) at 22 atm, resulting in an excellent angiographic result (Figure 4). This case required 2 hours to complete.

Discussion. We report our experience involving 1 patient who had a totally occluded anomalous RCA arising from the left sinus of Valsalva who was successfully treated with the implantation of multiple overlapping drug-eluting stents (“full-metal jacket” technique). It has been suggested that the abnormal origin and course of anomalous coronary arteries could make them more prone to atherosclerosis due to altered flow patterns. However, there are no definitive data on whether anomalous coronary arteries are more or less prone to atherosclerosis than normally arising ones.⁸ The lesion treated in our patient, like in other reported cases, was located in the mid-segment of the anomalous RCA (suggesting that this segment may be susceptible to accelerated atherosclerosis) and was totally occluded, making the procedure even more challenging. The anomalous origin of the RCA from the left sinus of Valsalva is difficult to reach with standard catheters, and PCI requires more secure guiding catheter support compared to the normally-situated RCA. Choosing the appropriate guiding catheter is the most important factor in determining procedural success.² A guiding catheter with a curve that seats against the posterior wall of the aorta, such as the Amplatz, XB or Voda catheters, provide the reliable backup needed for the intervention.^3–7 In this case, a left Amplatz II guiding catheter provided excellent backup support for crossing the total occlusion and passage of multiple stents and postdilatation balloon catheters.

The choice of guidewire can also affect the final outcome. In our case, we used the Choice PT2 guidewire (Boston Scientific) like Spargias et al, who found that use of a soft, hydrophilic wire offered an advantage over stiffer, nonhydrophilic wires that require enhanced guiding catheter support.⁸ PCI for chronic total occlusion (CTO) in anomalous coronary arteries presents one of the most technically challenging cases for interventional cardiologists. Recently, several techniques and devices have been introduced to improve angiographic success rates in patients with CTOs. We used the anchoring technique to facilitate the guidewire crossing to the distal vessel. In a recently published article by Kaneda et al, they describe a case of successful PCI for CTO in an anomalous RCA using several techniques including the retrograde approach via a collateral vessel, the anchoring technique and the five-in-six system.⁹ No reliable estimate of the likelihood of success with angioplasty and stenting of such arteries is available (failures are unlikely to be reported), however, because these cases are rare, the reported experiences of other practitioners may provide helpful tips.

References

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9. Kaneda H, Takahashi S, Saito S. Successful coronary intervention for chronic total occlusion on an anomalous right coronary artery using the retrograde approach via a collateral vessel. J Invasive Cardiol 2007;19:1–4.