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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 89-91

Intervention on anomalous left anterior descending artery originating from right coronary sinus


Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Date of Submission18-Mar-2020
Date of Decision12-Apr-2020
Date of Acceptance19-Apr-2020
Date of Web Publication25-Sep-2020

Correspondence Address:
Dr. B S Arun
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannergatta Road, Jayanagar-9th Block, Bengaluru - 560 069, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_8_20

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  Abstract 


Coronary arteries anomalies are rare. We report a case of anterior wall myocardial infarction with anomalous left anterior descending artery (LAD) and left circumflex artery (LCX), with LAD originating from right coronary sinus and LCX from right coronary artery. We did successful percutaneous coronary intervention with stenting to LAD using Amplatzer AR1-catheter.

Keywords: Amplatzer catheter, coronary artery anomaly, myocardial infarction, percutaneous coronary intervention


How to cite this article:
Bijapur S, Arun B S, Manjunath C N, Bhat P. Intervention on anomalous left anterior descending artery originating from right coronary sinus. J Indian coll cardiol 2020;10:89-91

How to cite this URL:
Bijapur S, Arun B S, Manjunath C N, Bhat P. Intervention on anomalous left anterior descending artery originating from right coronary sinus. J Indian coll cardiol [serial online] 2020 [cited 2020 Oct 23];10:89-91. Available from: https://www.joicc.org/text.asp?2020/10/2/89/296125




  Introduction Top


Anomalous coronary arteries are observed in approximately 1% of patients undergoing coronary angiography (CAG).[1] These are usually compatible with normal life, but, sometimes leads to catastrophic complications. The anomalous origin of the coronary artery can occasionally be associated with acquired heart disease, including coronary artery disease. Sudden death and exercise-related death are most common with the anomalous origin of the left main from the right coronary sinus (RCS). The high-risk anatomies responsible for sudden death are a coronary artery segment coursing between the pulmonary artery and the aorta. In these patients, the identification of the coronary ostium and revascularization is difficult.[1],[2] Here we report a case of left anterior descending artery (LAD) originating from RCS.


  Case Report Top


A 60-year-old male presented with a history of chest pain since 4 h. On examination, pulse rate was 80 beats/min. Blood pressure was 110/74 mmHg. Cardiovascular and other systemic examination was unremarkable. There were no comorbidities. No history of substance abuse. There was no family history of cardiac disorder or sudden death.

Electrocardiogram (ECG) showed ST elevation in V1–V6. On echocardiography, he had hypokinesia of basal and mid anterior, anteroseptal, anterolateral, apical anterior segments, thickness was preserved. The left ventricular ejection fraction (LVEF) was 40%. The patient was diagnosed with acute anterior wall myocardial infarction, Killip Class 1, moderate left ventricular (LV) dysfunction. Options of primary percutaneous coronary intervention (PCI) and thrombolysis were given and patient's relatives opted for thrombolysis. He was initially managed with thrombolysis, antiplatelets, heparin, and statin.

Later, he was considered for CAG through right radial artery approach, as he had recurrence of angina. On CAG, LAD was not detected despite multiple attempts with TIGER catheter with shoots taken in left coronary sinus. On taking shoots in RCS, right coronary artery (RCA) was super-dominant [Figure 1] and [Video 1]. Distal RCA had mild plaquing. Posterior decending artery has 60% stenosis. LAD and left circumflex artery (LCX) had separate origin. Left main coronary artery was absent. LAD was found to have anomalous origin from RCS. It was type II LAD [Figure 2]; [Video 2] and [Video 3]. Ostial LAD has mild plaquing. Proximal LAD has 70% stenosis and mid LAD has total occlusion. LCX had anomalous origin from proximal RCA, nondominant, small and normal [Figure 3]; [Video 4] and [Video 5].
Figure 1: The right coronary artery is superdominant with its distal branches coursing retrogradely in the left atrioventricular groove (in the course of the normal left circumflex artery) and supplying the left ventricle. Posterior descending artery has 60% stenosis

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Figure 2: The anomalous left anterior descending artery originating from right coronary sinus. Proximal left anterior descending artery has 70% stenosis and mid left anterior descending artery has total occlusion. Left circumflex artery had anomalous origin from proximal right coronary artery, nondominant, small and normal

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Figure 3: Left anterior descending artery was type II and after major diagonal, it was small caliber. Hence, guidewire was passed from mid left anterior descending artery to major diagonal

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Angiographically, there were no features to suggest interarterial or transseptal course of LAD. Although computed tomography-CAG was ideally required to rule out interarterial and transseptal course of anomalous LAD, because of ongoing angina and nonaccessability, the patient was planned for PCI with stenting to LAD through right femoral artery access. 6F Amplatzer (AR1) guiding catheter was used to engage anomalous LAD originating from RCS. 0.014” Floppy guidewire was used to cross the lesion. After major diagonal, LAD was small Caliber vessel. Hence, guidewire was passed from mid LAD to major diagonal [Figure 3]. The lesion was predilated with 1.5 mm × 10 mm semi-compliant balloon at 12–14 atm. Then stenting was done in mid LAD→Diagonal using 2.75 mm × 18 mm drug eluting stent (DES), deployed at 11 atm [Figure 4]; [Video 6] and [Video 7]. Then, 70% lesion in proximal LAD was covered with 3 mm × 12 mm DES, deployed at 11 atm [Figure 5] and [Video 8]. TIMI III flow was achieved [Figure 6] and [Video 9].
Figure 4: Description: Stenting was done in mid left anterior descending artery → Diagonal using 2.75 mm × 18 mm drug eluting stent, deployed at 11 atm

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Figure 5: Stenting of proximal left anterior descending artery with 3 mm × 12 mm drug eluting stent, deployed at 11 atm

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Figure 6: Final Angiogram showing TIMI III flow in the left anterior descending artery and major diagonal

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  Discussion Top


The most common anomaly of coronaries is the separate origin of LAD and LCX, with an incidence of 0.41%, followed by LCX arising from the RCA, with an incidence of 0.37%.[2],[3],[4] An anomalous origin of the LAD from the right sinus of valsalva is a rare coronary artery abnormality. The incidence of this anomaly has been reported to be 0.01%–0.07% among patients undergoing cardiac catheterization, and 1.2%–6.1% in those with an isolated coronary artery anomaly.[2],[3]

There are three variations in the initial course of the anomalous LAD, originating from RCS: (1) anterior to the right ventricular infundibulum (anterior type), (2) between the aorta and the pulmonary trunk (interarterial type), and (3) in the ventricular septum (septal type).[4] The anterior type is the most common type (50%).[4]

This anomaly has been considered clinically of no significance probably because majority of patients with this anomaly are asymptomatic.[5],[6],[7] No particular attention was paid to this coronary anomaly in the largest series by Yamanaka and Hobbs.[6]

In our patient, LAD had anomalous origin from RCS and has significant stenosis. In such cases, it will be difficult to engage LAD with usual guiding catheters, which we managed to do with AR1 catheter and successfully completed angioplasty with stenting to LAD.

The patient is in follow-up with us since the past 6 months. He is doing well, with no angina or dyspnea. Follow-up echo showed improvement in LV systolic function with LVEF of 48%.


  Conclusion Top


Anomalous origin of coronary arteries is rare, but a great challenge during PCI. Routine catheters may not be successful in engaging such coronaries. In such cases, special catheters may have to be used.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Angelini P, Velasco JA, Flamm S. Coronary anomalies: Incidence, pathophysiology, and clinical relevance. Circulation 2002;105:2449-54.  Back to cited text no. 1
    
2.
Ali R, Tahir A, Shakhatreh MI, Posina KV. Anomalous origin of coronary arteries arising from the right coronary cusp: A rare presentation. Cureus 2018;10:e2535.  Back to cited text no. 2
    
3.
Alexander RW, Griffith GC. Anomalies of the coronary arteries and their clinical significance. Circulation 1956;14:800-5.  Back to cited text no. 3
    
4.
Jariwala P, Lingareddy S, Koduganti S. Anomalous origin of the common left coronary artery from the right coronary sinus: An unusual anatomical variation. JACC Cardiovasc Interv 2014;7:e147-9.  Back to cited text no. 4
    
5.
Kimbiris D. Anomalous origin of the left main coronary artery from the right sinus of Valsalva. Am J Cardiol 1985;55:765-9.  Back to cited text no. 5
    
6.
Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28-40.  Back to cited text no. 6
    
7.
Ono M, Brown DA, Wolf RK. Two cases of anomalous origin of LAD from right coronary artery requiring coronary artery bypass. Cardiovasc Surg 2003;11:90-2.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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