Successful Transradial Intervention for Two Lesions with Dual Anomalous Origins of Coronary Arteries

ABSTRACT: A 76-year-old male was admitted to our hospital for effort angina pectoris. His coronary computed tomography and coronary angiography revealed anomalous origins of the left anterior descending artery (LAD) from the proximal right coronary artery (RCA) and the left circumflex coronary artery (LCX) from the separate ostium in the right coronary cusp. Severe stenoses were present in the proximal segment of the LAD and in the middle segment of the LCX, which were successfully treated by 5 French (Fr) transradial approach intervention. Congenital coronary anomalies are relatively rare, with a prevalence of approximately 1.3% in a large-series study undergoing coronary angiography. Such anomalies occur in several anatomical arrangements, which have been classified in a number of research reports. Here we describe previously unreported dual anomalous origins of coronary arteries associated with significant atherosclerotic lesions, which were successfully treated by 5 Fr transradial approach intervention.

J INVASIVE CARDIOL 2011;23:E117–E120

Key words: congenital coronary anomaly, transradial intervention, 5 Fr guiding catheter, Ikari catheter, slender PCI

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We describe a case of previously unreported dual anomalous origins of coronary arteries associated with significant atherosclerotic lesions, which was successfully treated by 5 French (Fr) transradial approach intervention.

Case Report. A 76-year-old male was admitted to our hospital for effort angina pectoris. His risk factors for coronary artery disease included hyperlipidemia and hypertension. His clinical examination and resting electrocardiogram were unremarkable. An echocardiogram demonstrated normal left ventricular function, with an ejection fraction of 65%. Figure 1 shows the axial view of the multi-detector computed tomography (MDCT) and the schematic representation of the view. These studies showed an abnormal course of the coronary arteries. The left anterior descending artery (LAD) branched off the proximal right coronary artery (RCA) and flowed through the anterior aorta. The left circumflex coronary artery (LCX) arose from the separate ostium in the right coronary cusp and flowed through between the aorta and the pulmonary artery, and the posterior aorta. Figure 2 shows the volume rendering (VR) view and the curved multiplanar reconstruction (CPR) views of the MDCT. VR view of the left coronary artery (LCA) revealed only an intermediate ramus and a diagonal branch, without main branches of the LAD and the LCX. Indeed, VR views revealed that the RCA included the anomalous origin of the LAD from the proximal RCA, and that the LCX arose from the separate ostium in the posterior right coronary cusp (RCC). CPR views revealed significant atherosclerotic lesions in the proximal segment of the LAD and the middle segment of the LCX.

Coronary angiography was performed through the right radial artery. The angiogram revealed findings similar to the MDCT. First, the RCA could be cannulated with a 5 Fr Heartrail™ Ikari Left 4.0 curve (Terumo Corporation, Tokyo, Japan) (Figure 3A). After the 0.014˝ Asahi Sion™ guidewire (Asahi Intecc, Nagoya, Japan) was inserted into the RCA, the other 0.014˝ Runthrough™ NS guidewire (Terumo Corporation) was inserted into the anomalous origin of the LAD with pulling up and rotating counter-clockwise the guiding catheter a little. The stenosis was evaluated by intravascular ultrasound (IVUS) ViewIT® (Terumo Corporation) (Figure 3B). The IVUS showed a focal eccentric plaque with attenuation in the LAD lesions. A 2.5 x 12 mm Xience V™ stent (Abbott Vascular, Santa Clara, California) was then implanted at 12 atm (Figures 3C and 3D). Then, the same guiding catheter could cannulate into the LCX that arose from the separate ostium in the posterior right coronary cusp (Figure 4A). The 0.014˝ Runthrough™ NS guidewire was inserted into the LCX, and IVUS showed a focal concentric fibrous plaque with negative remodeling in the LCX lesions (Figure 4B). A 2.75 x 15 mm Xience V stent was implanted at 12 atm (Figures 4C and 4D). The final angiogram showed optimal angiographic results in both lesions. The procedure time was 45 minutes, with 19.5 minutes of fluoroscopy and 125 ml of contrast used. The patient had no complications during hospitalization and was discharged the next morning.

Discussion. Congenital coronary anomalies are relatively rare, with a prevalence of approximately 1.3% in a large-series study of patients undergoing coronary angiography.¹ Such anomalies occur in several anatomical arrangements, which have been classified in a number of research reports.^2–5 A separate origin of the LAD and the LCX was the most common anomaly, followed by an origin of the LCX arising from the RCA or the RCC and an origin of the RCA arising from the left coronary cusp. However, there were few reports of a patient presenting with multiple diseased anomalous coronary arteries simultaneously.

The coronary intervention of a diseased anomalous coronary artery is technically difficult because of the configuration of the ostium and the acute angle of the vessel takeoff. Appropriate selection of a guiding catheter is one of the most important keys to successful PCI for the diseased anomalous coronary artery.^6–12 Youssef et al reported the rate of engagement success using only the Ikari-Left guiding catheter to be 99.4% in the LCA and 98.1% in the RCA; the rate of device success was 98.6% in the LCA and 97.6% in the RCA in 621 cases.¹³ The shape of the Ikari-Left guiding catheter is very useful as a catheter for multipurpose use in the LCA and RCA. In our clinical practice, we have observed that a small-sized guiding catheter may be easier than a large-sized one to engage in the coronary artery. One of the reasons a 5 Fr guiding catheter can be more easily engaged in a coaxial position is that a smaller-sized guiding catheter is flexible and deformable by manipulating in the body. Even if the catheter shape is not a perfect match for the configuration of the ostium, we can often engage with minimal manipulation.

On the other hand, it is an indisputable fact that a small-sized guiding catheter has lower backup force than a large-sized one. However, the Ikari-Left guiding catheter was reported to have greater backup force for the LCA and RCA than Judkins-Left and backup (EBU/XB)-type guiding catheters for the LCA, and Judkins-Right and Amplatz-Left for the RCA in transradial interventions.^14,15 Thus, the use of the Ikari-Left guiding catheter may overcome the limitations of low backup force of 5 Fr PCI. For all of these reasons, we selected a 5 Fr Ikari-Left guiding catheter for PCI in these anomalous coronary arteries, and we successfully completed the procedure.

Recently, both simple and complex PCIs have been reported to be practical in selected patients with 5 Fr PCI;²² for example, in a bifurcation lesion with kissing balloon technique;¹⁶ in PCI with a distal protection device;¹⁷ in a severely calcified lesion with rotational atherectomy;¹⁸ and in chronic total occlusion lesions.^19–21 Moreover, pre-PCI CT angiogram (CTA) providing visualization of coronary tree anatomy and plaque characteristics is helpful for planning PCI strategy.^23,24 Therefore, if we find that pre-PCI CTA suggests a 5 Fr approach will be feasible, it may be possible to perform safer and less invasive PCI with a smaller guide catheter approach using supportive guides even in challenging anatomic situations such as the anomalous arteries described in this report.

In conclusion, 5 Fr PCI for anomalous coronary artery lesions is feasible and should become one of the options for anomalous coronary artery PCI.

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From the Department of Cardiology, Tokai University School of Medicine, Ise- hara, Kanagawa, Japan.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted July 28, 2010, provisional acceptance given September 13, 2010, final version accepted October 4, 2010.
Address for correspondence: Naoki Masuda, MD, Assistant Professor, Depart- ment of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Ise- hara, Kanagawa, 259-1193, Japan. Email: nmasuda@is.icc.u-tokai.ac.jp