Letters to the Editor

Similar Case of Anomalous Origin

I read the article regarding a single coronary artery by Namboodiri et al,¹ published in the April 2007 issue of the Journal of Invasive Cardiology, with great interest. However, the authors missed referencing a few important publications related to their article. I had already reported a similar case of anomalous origin of the left anterior descending artery (LAD) from the right coronary sinus having a septal course, absence of a left circumflex artery (LCx), and an unusual dominant course of the right coronary artery (RCA) in the International Journal of Cardiology in June of 2005.² Similarly, their comment about providing the only publication of direct continuation of the LCx from the terminal RCA also does not hold true, as it has been reported in the past by several clinicians.^{3– 5} Although the septal course of the LAD is clarified in the RAO and AP views by the authors, an additional LAO cranial view would have more clearly demonstrated the septal course of the LAD and also the unusual dominant course of the RCA. I do agree with the authors about the benign course of the anomaly, as my case also did not have any inducible myocardial ischemia despite having a similar anomaly.

Rajesh Vijayvergiya, MD, DM

Assistant Professor

Department of Cardiology

Post Graduate Institute of Medical Education & Research (PGIMER)

Chandigarh 160012 India

E-mail: rajeshvijay999@hotmail.com

References

1. Namboodiri N, Harikrishnan S, Tharakan JA. Single coronary artery from right aortic sinus with septal course of left anterior descending artery and left circumflex artery as continuation of right coronary artery: A hitherto unreported coronary anomaly. J Invasive Cardiol 2007;19:E102–E103.

2. Vijayvergiya R, Kumar Jaswal R. Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: A case report. Int J Cardiol 2005; 102: 147– 148.

3. Ilia R, Jafari J, Weinstein JM, Battler A. Absent left circumflex coronary artery. Cathet Cardiovasc Diagn 1994; 32:349–50.

4. Kumar K. Anomalous course and branches of human coronary arteries. Acta Anat 1989; 136: 315– 318.

5. Barresi V, Susmano A, Colandrea MA, et al. Congenital absence of the circumflex coronary artery: Clinical and cinearteriographic observations. Am Heart J 1973; 86:811–816.

Carotid Artery In-Stent Restenosis Resolved with Drug-Eluting Stenting

We were pleased to have our Clinical Decision Making article "Carotid Artery In-Stent Restenosis in a Patient with Contralateral Total Occlusion, Resolved with Drug-Eluting Stenting" published in the June 2007 issue of the Journal of Invasive Cardiology (2007;19:275–279). We are particularly compelled to respond to Dr. Nanjundappa’s commentary on our case. We had considered, as Dr. Nanjundappa did, that restenosis in this case was not a benign process. It was clear that this was a true restenosis, as reflected by the velocities on Doppler examination (systolic velocity of 400 cm/sec, diastolic velocity of 120 cm/sec), and we proceeded in consequence. Keeping in mind the study by Abou-Chebl et al "Drug- Eluting Stents for the Treatment of Intracranial Atherosclerosis: Initial Experience and Midterm Angiographic Follow-Up" published in Stroke (2005;36:168–265), we considered implantation of a drugeluting stent to be a good option. Their study demonstrated good results with drug-eluting stents in carotid arteries and no toxic effects. In fact, this is supported by Gupta and colleagues’ study published recently in Stroke (2006;37;2562–2566) "Safety, Feasibility, and Short-Term Follow-Up of Drug-Eluting Stent Placement in the Intracranial and Extracranial Circulation".

We were not preoccupied by the possible deformation of the stent because its position was high in the internal carotid artery and mechanical protection was provided by the previous self-expanding stent.

Dr. Nanjundappa’s remark about using an undersized balloon was very pertinent, but in this case of major emergency, it was the only option we had (we expanded the balloon to 18 atm to achieve the maximum diameter). Finally, we can extrapolate that the drug-eluting stent thrombosis into the left main coronary artery produced the same catastrophic consequences as in the carotid arteries (in our case, the right carotid artery); this, however, did not diminish our enthusiasm for placing drug-eluting stents in the left main artery.

Adrian Iancu, MD and *Alexandra Lazar, MD

University of Medicine “Iuliu Hatieganu” Cluj-Napoca and the *Heart Institute,

“N. Stancioiu” Cluj-Napoca, Clinic of Cardiology, Cluj, Romania

Difficult Anatomies: Use Three Hands

Today’s interventional cardiologist is armed with a vast array of devices for treatment of increasingly difficult lesions. Inhospitable anatomies previously considered suitable only for surgical therapy are now frequently accessible with modern tools and techniques. Extra back-up guiding catheters as well as extra-support guidewires provide solid platforms for device delivery. “Buddy wires” help to deflect stents from vessel wall calcifications while the Wiggle Wire (Guidant Corp., Indianapolis, Indiana) actually allows the stent to bounce away from potential obstacles. Alternatively, the Rotaglide (Boston Scientific Corp., Natick, Massachusetts) lubricant has been applied directly to the undeployed stent surface to successfully overcome vessel resistance.¹

Nonetheless, at times, a simple maneuver can provide just enough “push” to accomplish device delivery. For example, deep inspiration causes caudal displacement of the diaphragm as well as the heart. This action can potentially ameliorate an acute vessel segment angulation. The relative negative intrathoracic pressure thus generated may also aid in drawing the device centrally.²

During routine device delivery, most operators advance over-the-wire devices with the right hand, while holding the Touhy connector with the left. The guidewire is stabilized by the scrubbing assistant. When using rapid exchange systems, the Touhy connector may be held with the left middle and ring fingers while the device is advanced with the thumb and index finger. The wire is affixed with the operator’s right hand in this case. If device transit results in guiding catheter disengagement, the catheter is repositioned over the taut wire/device system, and the attempt is repeated. However, subsequent device delivery frequently produces identical catheter “back-out”, as there is no concurrent counteracting forward force to maintain catheter engagement.

We have found, however, that simultaneous forward force on the guiding catheter during device advancement, with concomitant stabilization of the Touhy connector greatly enhances delivery success. In this case, the operator’s left hand maintains constant forward pressure on the guiding catheter shaft just proximal to the access sheath. The right thumb and index finger are used to advance the device, while the middle and ring fingers grasp the side-port of the Touhy connector, exerting gentle opposing (backward) force to enhance device delivery. This simultaneous push-pull action allows for more focused control of advancement. The scrubbing assistant holds the guidewire close to the exit site and maintains firm wire position (Figure 1).

This method is applicable to both over-the-wire and rapid exchange platforms. In cases where traditional equipment delivery techniques result in guiding catheter extrusion or “back-out”, we have frequently experienced success using this simple maneuver, obviating the need for a second wire or equipment change. For more challenging anatomies, this technique can of course be employed in conjunction with other means of device transit facilitation.

Jack P. Chen, MD

Northside Cardiology, PC

Atlanta, Georgia

References

1. Chan AW, Ramee SR, Collins T, et al. Rotaglide-facilitated stent delivery: Mission accomplished. Catheter Cardiovasc Interv 2003;59:477–481.

2. Chen JP. Difficult anatomies — Just hold your (patient’s) breath. J Invasive Cardiol 2006;18:642.