Intramural Aortic Stenting of an Anomalous Right Coronary Artery Arising From the Left Valsalva Sinus: A Leap Into the Dark?

A 69-year-old man with unstable angina underwent coronary angiography showing no lesion in the left coronary artery and critical stenosis in the proximal right coronary artery (RCA) arising from the left sinus of Valsalva (Figure 1).  Notably, selective RCA engagement was possible only with a guide-catheter extension (Video 1). Moreover, intravascular ultrasound (IVUS) revealed an intramural aortic course (IAC) of the proximal RCA (Figure 2, Video 2).

A 3.5 x 26-mm drug-eluting stent was implanted and post-dilated in the intramural RCA with a good result (Figure 3). The clinical course was uneventful. After 12 months, the patient was asymptomatic and coronary computed tomography confirmed the good patency of the implanted stent (Figure 4).

IAC of coronary arteries is a neglected cause of angina in adult patients; surgical unroofing or coronary artery bypass graft are considered the gold standard treatments, although recently, stent implantation has been shown to be feasible and safe. Multimodality imaging is of paramount importance for diagnosis, treatment, and follow-up in this challenging setting.

Affiliations and Disclosures

From ¹Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy; ²Interventional Cardiology Department, S. Anna Hospital, ASST-Lariana, Como, Italy.

Drs Talanas and Dossi contributed equally to this work.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Giuseppe Talanas, MD, Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy. Via Enrico De Nicola, 07100 Sassari, Italy. Email: giuseppe.talanas@aouss.it.