|Year : 2020 | Volume
| Issue : 1 | Page : 16-21
PTCA in anomalous RCA arising from left sinus of valsalva - A case series
Veena Nanjappa, KS Sadanand, CN Manjunath
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Mysore, Karnataka, India
|Date of Submission||16-Jul-2019|
|Date of Decision||27-Dec-2019|
|Date of Acceptance||28-Dec-2019|
|Date of Web Publication||20-Apr-2020|
Dr. Veena Nanjappa
Sri Jayadeva Institute of Cardiovascular Sciences and Research, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Anomalous origin of the right coronary artery (AORCA) from the left sinus of Valsalva (LSOV) accounts for 6%–27% of all coronary anomalies. Systematic planning and selection of appropriate catheters are pertinent for successful results. On many occasions, it is not possible to selectively cannulate the vessel despite the use of multiple catheters or modified curves in them. Situation worsens in acute coronary syndrome scenario where valuable time is lost just trying to delineate the diseased coronary anatomy. Aims and Objectives: to study the guide catheter selection in cases of (Anomalous RCA) AORCA arising from left sinus of valsalva (LSOV). Materials and Methods: We encountered six cases of AORCA from left sinus of valsalva with significant coronary lesions in one year. Results: Three cases were done through transfemoral access and in three others cases the access was switched from transfemoral to right radial access. In two of these cases we adopted a double length coronary wire for performing the percutaneous transluminal coronary angioplasty (PTCA) as compared to the regular technique. Conclusion: In order for PTCA to be successful in anomalous coronary arteries, optimal guide catheter seating and catheter back up should be achieved, both of which may require modification in either the technique or change in access or alteration in the guiding catheter employed. While performing primary PCI, the operators and the ancillary staff need to be aware of this anomaly and be prepared. Exchanging guide catheter on coronary double length wire though cumbersome can ensure successful outcome. Change to right radial approach may confer an additional advantage of cannulating the vessel as the catheter gets support from the contralateral aortic wall.
Keywords: Anomalous origin of the right coronary artery, difficult percutaneous transluminal coronary angioplasty, percutaneous transluminal coronary angioplasty
|How to cite this article:|
Nanjappa V, Sadanand K S, Manjunath C N. PTCA in anomalous RCA arising from left sinus of valsalva - A case series. J Indian coll cardiol 2020;10:16-21
|How to cite this URL:|
Nanjappa V, Sadanand K S, Manjunath C N. PTCA in anomalous RCA arising from left sinus of valsalva - A case series. J Indian coll cardiol [serial online] 2020 [cited 2020 Aug 14];10:16-21. Available from: http://www.joicc.org/text.asp?2020/10/1/16/282973
| Introduction|| |
Coronary artery anomalies are uncommon and encountered in 0.2%–1.2%, of patients undergoing percutaneous angioplasties. Anomalous origin of the right coronary artery (AORCA) from the left sinus of Valsalva (LSOV) accounts for 6%–27% of all coronary anomalies. Systematic planning and selection of appropriate catheters are pertinent for successful results. On many occasions, it is not possible to selectively cannulate the vessel despite the use of multiple catheters or modified curves in catheters. Rarely, only diagnostic catheters are able to cannulate, whereas guide catheters are not able to do the same. The situation worsens in acute scenarios where valuable time is lost just trying to delineate the concerned coronary anatomy. We encountered six cases of AORCA from LSOV where percutaneous transluminal coronary angioplasty (PTCA) was successfully performed.
| Case Summary|| |
All cases were initially performed through transfemoral access. Switch over to radial access was done in three of the cases. Initially, after left coronary angiogram, RCA angiogram was done using diagnostic Judkins Right 3.5 catheter in left anterior oblique (LAO) 30 degree angulation.
In the first two cases, selective cannulation of RCA was not possible, despite the use of multiple catheters and modified curves of catheters. We then cannulated it with TIG 5F diagnostic catheter. The lesion was wired with double-length (300 cm) 0.014” Cougar coronary wire; we used a second exchange length wire as buddy wire for support. Diagnostic catheter was then slowly removed under fluoroscopy. The patient was stable throughout the exchange. Judkins Right 6F guide catheter was then threaded on the coronary wires using 0.025” Terumo hydrophilic wire for support till it reached the left sinus. Judkins Right could still not be manipulated to selectively cannulate in the second case [Figure 1] and [Figure 2]. We then used a short 2.5 mm × 8 mm balloon dilated it within the lesion, and used it as an anchor selectively cannulate the guide catheter. The lesions were adequately predilated with multiple sequential dilatations, stented, and optimized with good results. Coronary computed tomography (CT) done later in the second case revealed it to be an anomalous RCA arising from the left sinus and traversing the interarterial tunnel between the ascending aorta and the right ventricular outflow tract before entering the right atrioventricular groove [Figure 3].
|Figure 1: (a) Nonselective sinus injection showing anomalous type C origin (b) selective injection with 5F Tiger showing significant right coronary artery disease. (c) Wiring with 0.014” Cougar exchange length – 300 cm coronary wires, and removing the diagnostic 5F catheter gently. (d) Introducing 6F Judkins right guide on the coronary wires with help of 0.025” Terumo wire for support. (e) Balloon anchoring (2.5 × 8 mm semi- compliant balloon) to aid selective cannulation of the right coronary artery with guide catheter. (f) After stenting with 3.5 mm × 32 mm drug-eluting stent. (g) Final angiogram after post dilatation with noncompliant balloon at high atmospheric pressures|
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|Figure 2: Schematic representation of the technique: (a) Engaging with diagnostic 5F catheter and wiring with 0.014” exchange length wire and removing the diagnostic catheter gently under fluoroscopy. (b) Threading Judkins right 6Fr guide with the help of 0.025'' wire in the sinus|
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|Figure 3: (a and b) Multislice computed tomography with three-dimensional reconstruction demonstrating the right coronary artery arising from the left sinus of valsalva. It arises anterior and to the right of left coronary artery. It traverses between the aorta and the right ventricular outflow tract in an interarterial course before reaching the right atrioventricular groove. Proximal stented segment is seen which was reported to be patient|
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In the third and fourth cases, multiple attempts at cannulation of anomalous RCA through transfemoral access failed. Switching to right radial access was considered as a deliberate measure as we thought that the contralateral aortic wall would give support to cannulate the anomalous RCA. Extra backup (EBU)-3 and Amplatzer left-1 were used successfully in the third and fourth cases [Figure 4] and [Figure 5].
|Figure 4: (a) Nonselective injection of the right coronary artery showing the faint opacification of the right coronary artery and the left coronary artery with Judkins right catheter. (b) Right coronary artery anomalously originating from the left sinus closer to the midline and above the sinotubular junction. (c) Selectively cannulating with EBU-3 through right transradial access after failed attempt through transfemoral route. (d) Overlapping two drug eluting stents of 3 × 32 mm size being deployed after adequate predilatation. (e) Final angiogram after post dilatation done with 3 × 10 mm and 3.5 × 10 mm noncompliant balloon high atmospheric pressures|
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|Figure 5: (a) Nonselective injection of the right coronary artery showing the faintly opacified right coronary artery and left coronary artery with Judkins right catheter and right coronary artery seen anomalously origination from the midline above the sinotubular junction. (b) selectively cannulating with Amplatzer left-1 catheter through right transradial access after failed attempts through transfemoral route. (c) Right coronary artery angiogram after stenting with 3.5 mm × 28 mm drug-eluting stent and postdilatation with 1:1 noncompliant balloon at high atmospheric pressures|
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In the fifth case, a 47 year old gentleman presented with inferior wall myocardial infarction and multiple episodes of primary ventricular tachycardia and cardiac arrest. He was resuscitated and taken for primary PTCA. He had anomalous RCA type C with mid RCA total occlusion with brief episodes of cardiac arrest on table. Judkins Left 4, Judkins Left 5 and Extra back up 3 catheters were tried to selectively cannulate the RCA but were unsuccessful. We were able to nonselectively cannulate using Amplatzer right-2 guide and could wire the RCA nonselectively. Selective cannulation of catheter on coronary wire was not possible. Any little attempt to engage the guide on coronary wire was leading to wire and catheter being backed out. A second buddy wire to RCA could not be negotiated. We then wired Left anterior descending artery (LAD) nonselectively as the left main coronary artery (LMCA) was arising in close proximity to the RCA ostium. It gave us two advantages. We could then track the guide on both wires to near-selective cannulation and secondly it prevented any LMCA damage due to guide catheter handling. We were able to successfully complete the procedure [Figure 6]. [Table 1] gives a brief summary of the cases.
|Figure 6: (a) Nonselective injection in the left sinus showing mid-right coronary artery total occlusion. (b) Wiring of both right coronary artery and left anterior descending for catheter backup support; predilatation of the lesion. (c) Final result after deployment of two drug eluting stents|
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[Figure 7] is a schematic representation of the origin of RCA in the aforementioned cases.
|Figure 7: Schematic representation of the origin of the right coronary artery. In the first and third cases, right coronary artery was arising from the left sinus of Valsalva above the sinotubular junction. In all the other cases, it was below the sinotubular junction. The first, second and sixth cases were closer to the midline where we had to resort to the altered technique of guide catheter cannulation on an exchange length coronary wire|
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| Discussion|| |
Coronary artery anomalies are uncommon, and interventions in this subgroup of patients become challenging due to the anatomical variation. AORCA is not immune to the pathology of atherosclerosis. The angiographic incidence of AORCA is 0.09%–0.25%. The location and configuration of the ostium, its takeoff angle, lesion location, tortuosity, and presence of calcium and acuity of lesion determine the success of angioplasty. The ostia of anomalous arteries are difficult to engage with routine guide catheters owing to their juxta commissural location and their tangential course in relation to the aortic wall. The tools (guide catheters and access) and techniques differ, and most of the knowledge is based on consensus and the experience of high-volume operators.,
The normal coronary ostia are usually located below the sinotubular ridge, within the sinus of Valsalva, centrally located between the commissural attachments of the aortic cusps., Normally, the RCA, as it emerges from its ostium, lies deep in the epicardial fat between the pulmonary conus and the right atrium (RA) and is somewhat obscured by the right atrial appendage. Covered by fat, its course runs deep in the right atrioventricular sulcus with the right atrium cephalad and the right ventricle caudal [Figure 8].
|Figure 8: (Reproduced with permission) Normal right coronary artery arising from the right anterior sinus in (a) and the three-dimensional reconstructed image of the same in (b); (c) In left anterior oblique view4, the outflow tract of the left ventricle and aorta may schematically be regarded as a cylinder with bulge in the middle owing to the presence of aortic sinuses. An imaginary line drawn at the upper edge of the bulge marks, the plane dividing the aortic sinuses from the ascending aorta. Another vertical line is drawn along the long axis of the ascending aorta intersecting the aortic sinus and aortoventricular planes perpendicularly. The origin of the aorta above the sinotubular plane; B: origin just below the ostium of the left coronary artery; C: Origin below the sinotubular plane between the midline and the left coronary artery; D: origin along the midline. The Judkins left 5.0 guide catheter and extra backup 3.5 catheter were most successful in engaging the type A and type B right coronary artery origin, respectively. Amplatzer left guide catheter was successful for most of the type C right coronary artery origin anomalies in their study|
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Anomalous origin of the coronary artery from the opposite sinus of Valsalva is particularly important, as it has been associated with myocardial ischemia, ventricular arrhythmias, and sudden death, especially when the anomalous artery course is interarterial (between the aorta and the pulmonary). Sarkar et al. is the largest series of anomalous RCA with origin from left coronary sinus. In his series, 24 patients had anomalous RCA arising from left sinus of valsalva out of 40,000 consecutive angiograms. Three-dimensional (3D) CT angiography is an alternative and superior imaging tool to look into the AORCA with unresolved issues such as interarterial course or intramural course.,, In our second case, the elderly gentleman had interarterial RCA anomalously arising from the left sinus. In his 3D-CT reconstructed cardiac image, it is seen that the ostio-proximal segment is relatively narrow compared to the distal segments, and there was no angiographic or CT demonstrable evidence of plaque.
Several theories have been proposed as possible mechanisms leading to myocardial ischemia. First, the ostium of the anomalous vessel is frequently slit-like and likely compromises flow. Second, the vessel usually arises from the aorta at an acute angle, rather than perpendicularly, which may alter the flow profile. Finally, it has been suggested that the interarterial course places the anomalous vessel at risk of compression between the great arteries. Not all patients with interarterial course require surgical therapy. In older patients without symptoms, it can be benign. However, such patients should be counseled against strenuous exercises.
Successful percutaneous treatment of stenotic lesions in AORCA-LSOV has been reported infrequently in the literature mostly in the form of small case series.,, The average number of guide catheters used for a single PTCA of AORCA was three or more in a retrospective study by Uthayakumaran K et al, that indicates the challenges involved in the intervention of AORCA from LSOV.
The first and second cases demonstrate that a successful procedure can be still attempted with due care using a diagnostic catheter and exchanging a guide catheter on it after wiring with 0.014” double-length coronary wire.
Lorin et al. published two cases of stenting in an anomalous RCA using a 6F JL 5.0 guiding catheter through right radial access after being unable to cannulate the anomalous RCA through the femoral artery approach.
By traversing a shorter segment of the aorta, using transradial route, the effects of the distal anatomy on proximal catheter behavior are decreased. This is especially noticeable in right coronary interventions. The right coronary catheters when placed from right radial access provide superior backup support, as opposed to the support provided by the same catheter from femoral approach, in view of the fact that transradial placement allows for these catheters to obtain added support from the contralateral aortic wall, similar to the behavior of the EBU series guide catheters for the left coronary artery. We were able to selectively cannulate the RCA in our third and fourth cases after switching over to right radial access and using EBU-3 and AL1 catheters, respectively.
| Conclusion|| |
In order for percutaneous coronary intervention to be successful in anomalous coronary arteries, optimal guiding catheter seating and catheter back up should be achieved, both of which may require modification in the technique or change in access or guide catheter used. When performing primary PTCA, the operators and catheterization laboratory personnel have to be aware of this anomaly. Exchanging guide catheter on coronary double-length wire though cumbersome can ensure successful outcome. Change to right radial approach may confer an additional advantage of cannulating the vessel as the catheter gets support from contralateral aortic wall.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]