Successful Percutaneous Coronary Intervention for Severe Stenosis of an Anomalous Left Coronary Artery Originating from the Prox

An isolated, single coronary artery is a rare congenital anomaly with an incidence of 0.03% to 0.4% and an uncommon finding (0.6% to 1.3%) in patients undergoing coronary angiography.^1,2 In this report we describe a rare case of a patient who had an anomaly of the left and right coronary arteries with a single coronary ostium in the right sinus of Valsalva, in which percutaneous coronary intervention (PCI) was successfully performed in both arteries. Case Report. An 81-year-old female with a history of hypertension presented with unstable angina pectoris. Coronary angiography showed a single coronary artery that originated from a single ostium in the right sinus of Valsalva and gave rise to the right coronary artery (RCA) and left coronary artery (LCA) after a short main segment (Figure 1A). The LCA, after branching off the main segment above a 90° angle, divided into the left anterior descending (LAD) and left circumflex (LCX) arteries. A severe stenosis was noted in the proximal RCA and ostium and mid-portion of the LCA (Figure 1A). The proximal RCA lesion was selected first for PCI because the lesion was discrete and easily accessible, with a straight course. The main coronary artery was selectively cannulated via the right femoral artery using a 6 Fr Judkins right catheter (Cordis Corporation, Miami, Florida). The lesion was crossed with a 0.014 inch Balance Middleweight™ guidewire (Guidant Corporation, Indianapolis, Indiana), and a 3.0 x 32 mm Taxus® stent (Boston Scientific, Natick, Massachusetts) was placed after predilatation. The angiographic results after stenting were satisfactory, with no residual stenosis (Figure 1B). Six days after PCI of the RCA, we tried to perform a PCI of the LCA lesion. Because the LCA originated from the RCA with an acute angle, selection of a guiding catheter that had good back-up support and a proper angle for the ostium of the coronary artery was important. After several attempts using various kinds of guiding catheters, a 6 Fr Hockey Stick guiding catheter (Cordis) was chosen. The lesion was crossed with a 0.014 inch floppy guidewire (Guidant) and dilated with a 2.5 mm x 15 mm Sprinter balloon catheter (Medtronic, Inc., Minneapolis, Minnesota). No problems with the guiding support were encountered during manipulation of the balloon catheter and guidewire. However, despite a prolonged inflation of the balloon catheter with high pressure, the lesion did not improve due to elastic recoil (Figure 2A). Thus, we decided to implant a stent and selected a short bare metal stent (Carbo stent 2.5 x 9 mm, Sorin, Saluggia, Italy) for the possibility of delivery failure. However, we could not pass the stent through the ostial lesion of the LCA because the lesion was so tight and the guiding catheter was unable to provide adequate back-up support such as that achieved during balloon dilatation. After several more attempts, we stopped the procedure due to contrast volume overload and high radiation exposure. Fortunately, there was no evidence of coronary dissection where the artery was dilated by the balloon catheter. Two weeks after PCI of the LCA, despite optimal medical treatment, the patient was readmitted because of angina. The ostium of the main coronary artery was also selectively cannulated using a 6 Fr Hockey stick catheter. First, in order to achieve good back-up support for the guiding catheter, a 0.014 inch stiff guidewire (Guidant) was placed in the distal RCA. A 0.014 inch floppy guidewire (Guidant) was then passed through the LCA (Figure 2B). At that time, we decided to implant a stent directly, without any predilatation that could cause a coronary dissection. For the mid-portion of the LCA, we chose the 2.75 x 9 mm short, bare metal JoStent® (Boston Scientific, Natick, Massachusetts). At that time, we were able pass the stent through the ostial lesion of the LCA and successfully deployed it in the mid-portion of the LCA (Figure 2C). After PCI of the mid-portion of the LCA, we also successfully implanted a 2.75 x 9 mm short, bare metal JoStent in the ostial lesion of the LCA without any complications (Figure 2C). The angiographic results after stenting were satisfactory, with a residual stenosis of Discussion. There have been several reports regarding patients with anomalous coronary arteries with severe stenosis who underwent PCI like our patient.^3,4 However, to the best of our knowledge, this is the first such patient to have undergone PCI for multivessel coronary artery lesions. PCI of anomalous coronary arteries presents several technical challenges to interventional cardiologists. Choosing the best guiding catheter and other equipment is crucial to the technical success of the procedure. We chose a Hockey stick guiding catheter and used a double guidewire technique to improve the back-up support, which is critical. Usually, during PCI of lesions in single coronary arteries (common ostium for the RCA and LCA), it is difficult to choose the appropriate guiding catheter because of the unusual direction and tortuous angle of the coronary artery. Moreover, if a dissection develops after passing the guidewire or during the inflation of the balloon catheter, it may extend retrogradely, involving the origins of the LCA and RCA, and the consequences can be catastrophic. Thus, good back-up support for the guiding catheter is very important in that situation. Fortunately, in our case, during the first attempt of PCI in the LCA, a dissection did not develop after balloon inflation. However, in the second attempt, the double guidewire technique provided excellent back-up support for the guiding catheter. Initially, we had considered coronary artery bypass surgery or hybrid revascularization instead of PCI, but due to the patient’s advanced age and poor physical condition, we performed PCI, which resulted in successful management of her condition. Our case involved a patient who had an anatomic variation that has been only rarely reported. This is the first report of PCI being performed in both the LCA and RCA in such a patient using a double wire technique in order to improve the back-up support of the guiding catheter.

1. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28–40. 2. Garg N, Tewari S, Kapoor A, et al. Primary congenital anomalies of the coronary arteries: A coronary angiographic study. Int J Cardiol 2000;74:39–46. 3. Chan CHS, Berland J, Cribier A, et al. Angioplasty of the right coronary artery with origin of the all three coronary arteries from a single ostium in the right sinus of Valsalva. Am Heart J 1993;126:985–987. 4. Altun A, Erdogan O. Stent Implantation to the stenosed right coronary artery in a patient whose right and left coronary arteries originate from a single ostium in the right sinus of Valsalva. Cardiology in Review 2003;11:101–103.