Percutaneous Coronary Intervention of the Left Main Trunk in Congenitally Anomalous Single Coronary Artery

Anomalous origin of the coronary arteries is uncommon. Angiographic studies have found a prevalence of such a congenital anomaly in 0.6–1.3% of cases.1,2 Single coronary artery arising from the right sinus of Valsalva is even less common, occurring in 0.02–0.04% of patients undergoing coronary arteriography.2,3 Accordingly, few reports have described percutaneous coronary interventions (PCI) of a single anomalous coronary artery.4–7 This report is the first to illustrate PCI of an anomalous left main trunk (LMT) originating from the proximal right coronary artery (RCA). The importance of magnetic resonance (MR) as a diagnostic tool to define topographic anatomy in coronary anomalies is underscored. Case Report. A 79-year-old female was referred for cardiac catheterization for angina of new onset. She had prolonged chest pain at rest and associated ST-segment depression in the precordial leads on ECG. A transthoracic echocardiography showed hypokinesia of the left ventricular anterior wall and mild to moderate left ventricular dysfunction. Her cardiovascular risk factors consisted of hypertension and hyperlipidemia. Cardiac catheterization revealed a single coronary ostium in the right sinus of Valsalva. The left coronary artery (LCA) arose from the proximal RCA. The LMT showed a 90% focal stenosis in its mid portion (Figure 1). After administration of a bolus and infusion of abciximab, the single coronary ostium was engaged with a 6 French Amplatz (AL2) guiding catheter (Cook Cardiology, Bloomington, Indiana). The lesion could be easily crossed using an extra-support wire. The inflation of a 3.0 mm balloon produced a localized dissection and a 16-mm long, 3.5 mm stent was placed. The final result was excellent (Figure 2). To define the topographic relation between the LCA and the pulmonary trunk, we performed a fast gradient-echo magnetic resonance angiogram with axial multiplanar reconstruction. Despite the artifacts produced by the stent, the MR clearly demonstrated that the LCA crossed anterior to the pulmonary trunk before assuming its normal position (Figure 3). The patient was free of symptoms and exercise test was normal at 6-month follow-up. Discussion. A rare combination of single coronary artery originating from the right sinus of Valsalva and a focal stenosis of the anomalous LMT arising from the proximal RCA is reported (Figure 1). There are few reports in the literature of PCI in congenitally single coronary arteries.4–6 The first description of a multivessel percutaneous transluminal coronary angioplasty in an anomalous coronary artery was reported by Grenadier et al.7 To our knowledge, no PCI of an anomalous LMT originating from the RCA has been described. Theoretically, performing PCI of a single coronary artery increases the procedural risk since a complication leading to dissection (e.g., guiding-catheter induced) of the single ostium may be catastrophic. Practically, since the single ostium usually has a very large caliber, the risk of guiding catheter damage is low. In our case, the lesion characteristics (focal and in the mid portion of the LMT) made it suitable for percutaneous approach. Moreover, as frequently seen in this type of anomaly, the left coronary system was smaller than usual. This report suggests that in selected patients, a lesion in an LMT of anomalous origin may safely be treated with PCI. MR adds valuable information to coronary angiography in the topographic diagnosis of coronary anomaly.8 This is of particular clinical relevance if the course of the anomalous coronary artery (either the left or right) between the aorta and pulmonary trunk is suspected, since this constellation is associated with an increased risk of sudden death.9,10

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