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Iatrogenic Dissection of the Anomalous-Origin Right Coronary Artery and Left Sinus of Valsalva
Anomalous right coronary artery (RCA) originating from the left sinus of Valsalva is a rare congenital abnormality.1 Percutaneous coronary intervention (PCI) of the anomalous-origin RCA can be challenging.2–4 Coronary artery dissection extending into the aorta is a rare and life-threatening complication during PCI.5,6 Coronary stenting of the dissection entry point is often effective, whereas emergency surgery is required in cases with progressive expansion of the aortic dissection.5,6 We present a case of anomalous-origin RCA dissection extending into the left sinus of Valsalva during PCI.
Case Report. A 67-year-old man presented with inferior myocardial infarction. He had a history of hypertension and hyperlipidemia. Emergency coronary angiogram was performed.
Angiogram of the left coronary artery (LCA) showed no significant stenosis. The RCA could not be cannulated with a Judkins right 4.0, Judkins left 4.0, Judkins left 5.0, or Amplatz left 1.0 catheter. Aortography revealed the RCA originating from the left sinus of Valsalva. Non-selective injection showed severe stenosis of the proximal RCA and total occlusion of the distal RCA. PCI was performed using a 7 French (Fr), Amplatz left 2.0 guiding catheter with inadequate back-up support. The lesion was dilated with a 3.0 x 20 mm balloon catheter. A 3.5 x 23 mm Multi-link Zeta stent (Abbott Vascular, Abbott Park, Illinois) was then deployed in the distal lesion and a 4.0 x 23 mm Multi-link Zeta stent was deployed in the proximal lesion. Final angiogram showed normal flow restoration. He became free of symptoms and was discharged in a stable condition.
Six years later, the patient presented with unstable angina. Angiogram of the LCA 
showed no significant stenosis. Non-selective injection using an Amplatz left 2.0 catheter showed severe in-stent restenosis of the proximal RCA (Figure 1A). PCI was performed via the right femoral artery using a 7 Fr arterial long sheath. Although a 7 Fr, Amplatz left 2.0 guiding catheter was inadequate to get good back-up support, the lesion was crossed using a Runthrough hypercoat guidewire (Terumo Medical, Tokyo, Japan). The lesion was dilated with a 4.5 x 12 mm Voyager-NC balloon catheter (Abbott Vascular).
Injection of contrast medium after balloon dilatation showed proximal dissection of the RCA and progression of the dissection into the sinus of Valsalva (Figures 1B and 1C). To seal the entry point of the dissection, a 4.0 x 15 mm Multi-link Vision stent (Abbott Vascular) was deployed at the ostium of the RCA (Figure 1D). Post-dilatation was performed with a 4.5 x 12 mm Voyager-NC balloon catheter at 16 atm. The final angiographic result of the RCA appeared good. The angiogram showed the false lumen almost disappeared (Figures 1E and 1F). Intravascular ultrasonography revealed no false lumen outside the stent at the ostium of 
the RCA. Computed tomography, performed immediately post-stenting, showed no signs of aortic dissection. Enhanced multidetector computed tomography was performed 1 day post stenting. Three-dimensional volume-rendered image of the coronary arteries showed that both the RCA and LCA originated from the left sinus of Valsalva (Figure 2A). No signs of dissection were observed in the Valsalva or the ascending aorta (Figures 2B and 2C). The patient became free of symptoms and was discharged 7 days after the coronary intervention.
Discussion. To the best of our knowledge, the present case is the first case of iatrogenic dissection of the anomalous-origin RCA and left sinus of Valsalva. Anomalous RCA originating from the left sinus of Valsalva is found in only 0.2% of patients undergoing diagnostic coronary angiography.1 Several authors reported cases of PCI of anomalous RCA originating from the left sinus of Valsalva.2–4 Appropriate guiding catheter selection is important for successful angioplasty. Although Amplatz left and Judkins left guiding catheters have been selected for this anomaly, selective cannulation of the anomalous RCA and maintaining coaxial position might be technically difficult.2–4 In the present case, injury caused by the Amplatz guiding catheter and subsequent contrast injection was the possible mechanism of the dissection of the RCA and left sinus of Valsalva.
Retrograde dissection of the RCA extending into the sinus of Valsalva and ascending aorta is a rare and life-threatening complication during coronary angioplasty, with reported incidences ranging from 0.03–0.15%.5–7 Surgery has been selected in cases of extensive aortic dissection.5,6 In cases of localized aortic dissection, sealing the entry point of the dissection by coronary stenting has been reported to be effective.5,6 Conservative treatment is risky due to potential myocardial infarction.7 In the present case, with the RCA originating from the left sinus of Valsalva, we selected stent treatment to avoid the risk of progressive dissection extending to the left main coronary artery. Intravascular ultrasonography is useful to evaluate complete coverage of the coronary artery dissection post stenting.8 Computed tomography is a useful noninvasive modality to evaluate aortic dissection.9 In the present case, multidetector computed tomography, performed post stenting, revealed resolution of dissection of the left sinus of Valsalva. Takahashi and colleagues reported a case of progressive expansion of the catheter-induced dissecting aorta, even after stent deployment for covering the entry of the coronary dissection.10 Careful follow up is necessary for patients who develop iatrogenic dissection of the aorta.
References
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- Yip H, Chen MC, Wu CJ, et al. Primary angioplasty in acute inferior myocardial infarction with anomalous-origin right coronary arteries as infarct-related arteries: Focus on anatomic and clinical features, outcomes, selection of guiding catheters and management. J Invasive Cardiol 2001;13:290–297.
- Cohen MG, Tolleson TR, Peter RH, et al. Successful percutaneous coronary intervention with stent implantation in anomalous right coronary arteries arising from the left sinus of Valsalva: A report of two cases. Catheter Cardiovasc Interv 2002;55:105–108.
- Conde-Vela C, Sabaté M, Quevedo PJ, Hernández-Antolín R. Primary percutaneous coronary intervention of an anomalous right coronary artery originating from the left sinus of Valsalva. Acute Card Care 2006;8:229–232.
- Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387–393.
- Yip HK, Wu CJ, Yeh KH, et al. Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: A single-center experience and literature review. Chest 2001;119:493–501.
- Pérez-Castellano N, García-Fernández MA, García EJ, Delcán JL. Dissection of the aortic sinus of Valsalva complicating coronary catheterization: Cause, mechanism, evolution, and management. Cathet Cardiovasc Diagn 1998;43:273–279.
- Oda H, Hatada K, Sakai K, et al. Aortocoronary dissection resolved by coronary stenting guided by intracoronary ultrasound. Circ J 2004;68:389–391.
- Goldstein JA, Casserly IP, Katsiyiannis WT, et al. Aortocoronary dissection complicating a percutaneous coronary intervention. J Invasive Cardiol 2003;15:89–92.
- Takahashi Y, Tsutsumi Y, Monta O, et al. Closure of the left main trunk of the coronary artery and total arch replacement in acute type A dissection during coronary angiography. Ann Thorac Surg 2010;89:618–621.
