Percutaneous Coronary Artery Stenting of an Anomalous Right <br />
Coronary Artery with High Anterior Takeoff Using Standard Size 7 <br />

The anomalous right coronary artery (RCA) with high anterior takeoff is an uncommon, yet technically difficult vessel to cannulate, moreover to intervene upon. The high anterior location of the anomalous ostium is often difficult to reach with standard catheters and because of the immediate posterior direction of the vessel, percutaneous intervention requires more secure guiding catheter support compared to the normally located RCA. Several published case studies have described the technical difficulties associated with balloon angioplasty and stenting of anomalous RCAs and successful outcomes using a variety of guiding catheters. In this report, we describe 2 patients with anomalous RCAs and high anterior takeoff who had inadequate catheter engagement despite attempts with multiple different guiding catheters. Successful stent deployment was eventually performed using standard 7 French left Judkins guiding catheters that were securely engaged using vigorous clockwise torque. Case Report. Patient #1. A 62-year-old man presented with an acute coronary syndrome. Coronary angiography was performed with difficulty due to the presence of an anomalous RCA. Subselective injection using an Amplatz II catheter showed the anomalous high anterior takeoff of the RCA ostium and a long 75–80% stenosis in its mid-segment (Figure 1). Coronary angioplasty was attempted using a 7 French (Fr) Hockeystick, 3DRC, AL I, EBU 3.5, JL3.5, Multipurpose A2, AL II, LCB and GL3.5 guiding catheters without success. Of all catheters used, the tip of the JL3.5 came the closest to the RCA ostium and was tried again. With vigorous clockwise rotation, the tip of the catheter engaged the ostium of the RCA. Although the guiding catheter was not coaxial with the vessel, it allowed advancement of a 0.014´´ BMW-HC guidewire (Guidant Corporation, Temecula, California) into the vessel, which redirected the tip of the catheter into coaxial engagement with the vessel. A 3.0 x 18 mm S7 stent (Medtronic AVE, Santa Rosa, California) was delivered to the mid-RCA stenosis and deployed at 12 atmospheres (Figure 2). Intravascular ultrasound (IVUS) imaging using a 3 Fr Atlantis SR Plus (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) showed suboptimal stent expansion; therefore, the stent was dilated with a 3.0 x 15 mm High Sail balloon (Guidant Corporation) at 16 atmospheres, resulting in an excellent angiographic and IVUS result (Figure 3). This case took 3.5 hours to complete, with 100 minutes of fluoroscopy. Patient #2. A 53-year-old woman presented with an acute inferoposterior myocardial infarction and was successfully treated with thrombolytic therapy. During follow-up diagnostic angiography, there was great difficulty cannulating the ostium of the RCA due to the anterior and superior takeoff of the vessel. Despite use of multiple diagnostic catheters, only one adequate angiographic view of the RCA was obtained using a 6 Fr Amplatz II diagnostic catheter (Figure 4); it showed 3 serial 75–90% stenoses involving the proximal and mid-segments of the vessel. The left coronary artery was free of obstructive disease; therefore, percutaneous coronary intervention of the RCA was recommended. The patient had a small-caliber aortic root and as shown during diagnostic angiography, the AL II was too big. Seven Fr Hockeystick, AL I, AL 0.75, Multipurpose A2, 3DRC, AR I and GL3.5 guiding catheters were tried, but none of them adequately engaged the ostium of the vessel. Although a 0.014´´ BMW guidewire was advanced beyond the first lesion using the GL3.5 guiding catheter and a Transit catheter (Cordis Corporation, Miami, Florida), there was insufficient backup support for further advancement of the guidewire. Because an aortic root cusp injection showed that the right coronary ostium was near the left main ostium, a JL4 guiding catheter was tried. With clockwise torque, the tip engaged the ostium, but as with patient #1, the catheter was not coaxial with the vessel (Figure 5). Catheter engagement was sufficient to allow advancement of the 0.14´´ BMW guidewire beyond all 3 stenoses and into the distal RCA. Passage of the guidewire redirected the tip of the catheter into a more clockwise and coaxial position (Figure 6). The 3 stenoses were predilated with a 2.5 x 10 mm Stormer Balloon (Medtronic AVE, Santa Rosa, California) and a 3.0 x 13 mm Bx Velocity stent (Cordis Corporation) delivered to the mid-stenosis, a 3.0 x 8 mm Bx Velocity stent to the second mid-stenosis and a 3.0 x 15 mm S670 stent (Medtronic AVE) to the proximal stenosis. Because of suboptimal stent expansion noted by IVUS imaging, all 3 stents were post-dilated with a 3.5 x 8 mm High Sail balloon to 14 atmospheres. There were excellent angiographic and IVUS results at all stented sites (Figure 7). This case took 2 hours and 3 minutes to complete, with 55 minutes of fluoroscopy time. Discussion. The RCA with an anomalous origin is an uncommon1 and challenging vessel for percutaneous intervention, especially when there is a high anterior takeoff. Choosing the appropriate guiding catheter is the most important factor in determining procedural success. As exemplified by the cases described above, the technical difficulty of these anomalous vessels is reflected by the long procedural and fluoroscopy times, with most of the procedural time spent identifying the optimal guiding catheter. Once the proper guiding catheter was identified, completion of the cases including serial IVUS imaging and high-pressure balloon “post-dilation” took an average of 45 minutes. There are no published series of percutaneous coronary intervention on anomalous RCAs, but review of the international cardiology literature identified several case reports that described successful balloon angioplasty of anomalous RCAs using mostly Amplatz guiding catheters.2–4 Successful balloon angioplasty has also been reported using El Gamal, Block5 Voda6 and FL4-G (USCI) guiding catheters (the latter is a left Judkins-type left coronary guiding catheter with an eccentric tip).7 The first case report of successful stenting of an anomalous RCA was published by Olympios et al. in 1998,8 and was performed using an 8 Fr left Amplatz I guiding catheter. Laser angioplasty and laser-induced thrombolysis of anomalous RCAs have been successfully performed using 8 Fr left Amplatz I and II guiding catheters.9 Successful angioplasty and stenting of an anomalous RCA was described by Ng et al.10 using a 6 Fr left Judkins #5 catheter after failure with 7 Fr left Amplatz I and Multipurpose catheters. Cohen et al.11 also described successful stenting of anomalous RCAs using oversized 6 Fr left Judkins catheters. As described by the authors, the oversized secondary curve prevents the tip from engaging the left main ostium as the catheter is “pushed deep into the sinus of Valsalva, causing it to make an anterior and cephalad-pointing U-turn.” The resulting large curve of the catheter provided excellent back-up for stent delivery. Stenting of anomalous RCA lesions has also been reported using the right radial artery approach.12 As described by Ng10 and others,13 and as we experienced in our cases, the various Amplatz catheter sizes may either be too short or too long. If too short, the tip may not reach the ostium; if too long, the catheter may prolapse into the left ventricle. Although Ng attributes the success of the oversized 6 Fr left Judkins guiding catheter to the flexibility of 6 Fr catheters, in contrast to Cohen, he states that it only provided moderate back-up support, which may be sufficient only for treating straightforward proximal RCA lesions. Because the anomalous RCA ostium is anterior and superior in location, the standard size left Judkins catheter may be most suitable to engage the ostium, especially in patients with small diameter aortic roots. The engagement was sufficient in both of our cases to advance a guidewire, which redirected the catheter tip into a more stable clockwise and coaxial relationship with the vessel, which allowed passage of multiple stent, balloon and IVUS catheters. The cases described above illustrate that if Amplatz guiding catheters fail, early consideration should be made for using standard 7 Fr left Judkins catheters positioned with clockwise torque in order to provide a stable platform for intervening upon complex lesions of an anomalous RCA with high anterior takeoff. These catheters and techniques resulted in successful procedures when many other guiding catheters had failed, provided excellent back-up support for passage of multiple stents, intravascular ultrasound catheters and post-dilatation balloon catheters and hopefully will reduce procedural and fluoroscopy times.

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