Catheterization and Cardiovascular Diagnosis 22:39-41 (1991)
Percutaneous Transluminal Coronary Angioplasty of Anomalous Right Coronary Artery Bart Musial, MD, Alan Schob, MD, Eduardo de Marchena, MD, and Kenneth M. Kessler, M D Coronary angioplasty of tortuous anomalous coronary arteries can be technically challenging. We describe a successful percutaneous transluminal coronary angioplasty (PTCA) of an anomalous right coronary artery after a failed previous attempt. The anatomic limitations of anomolous right coronary arteries and technical considerations for PTCA are discussed. Key words: coronary artery disease, PTCA, anatomic limitations,
Coronary artery anomalies are found in approximately 1% of the adult population undergoing cardiac catheterization. Certain anomalies may be associated with an increased incidence of obstructive coronary artery disease [l]. With the expanded use and technical advances of percutaneous transluminal coronary angioplasty (PTCA) in the treatment of coronary artery disease even patients with abnormal anatomy have become candidates for its application. There have been reports of PTCA of anomalous coronary arteries [3-61 but only 1 prior report of PTCA of an anomalous right coronary artery (RCA) [ 3 ] . The unusual origins and abberant courses of those arteries present problems in terms of backup support for PTCA. Occassionally , special guiding catheter modifications have been performed in order to obtain adequate support for these technically complicated and challenging angioplasties [4-61. We present a patient who underwent PTCA of a critically stenotic anomalous RCA after a previous unsuccessful attempt. A 64 yr-old black male with a 1 yr history of unstable angina underwent cardiac catheterization. Coronary angiography showed a 95% proximal stenosis of an anomalous RCA. The dominant RCA arose from the anterior aspect of the left sinus of valsalva and after a short (1 cm) initial straight segment abruptly took a caudal anterior course between the great vessels before returning to its normal distribution. After the sino-atrial branch a long irregular 95% stenosis was present. The left coronary artery exhibited only luminal irregularities. Mild posterior wall hypokinesia was noted on left ventriculography. PTCA using standard balloon over a wire technique through standard 8F modified Amplatz RCA, Judkins RCA, and multipurpose guiding catheters was attempted. Although the lesion was successfully crossed with a standard coronary guidewire, a low-profile bal0 1991 Wiley-Liss, Inc.
loon (USCI 2.0 mm profile plus) could not be advanced across the lesion due to lesion severity and poor backup from any of the guiding catheters. The patient was treated with antianginal medication with good initial control of symptoms. After 18 mo the patient returned with worsening symptoms. A thallium exercise stress test demonstrated a large area of reperfusion in the inferior wall. A cardiac catheterization revealed no significant change (Fig. 1). A second PTCA was attempted with different guiding and dilation catheters. The anomalous RCA was successfully cannulated with an 8F soft-tip Amplatz Left I guiding catheter (Schneider). A 0.014 guidewire (USCI Veriflex) was used to cross the stenosis but a 3.0 mm Trac plus PTCA balloon catheter (SciMed) was unable to cross lesion due to poor guiding catheter back-up. The guidewire and balloon were removed and a steerable 1.5 mm dilating guidewire (SciMed DGW) was then used to successfully pass and predilate the stenosis. Two inflations were performed at 10 atm for 2 min. This was exchanged for a 3.0 ACE PTCA balloon catheter (Sci-Med). The lesion was easily crossed and 3 inflations were performed at 8 atm. Angiograms revealed dilation of the 95% lesion (Fig. 1) to a 10% residual stenosis (Fig. 2). A small dissection was present in the proximal aspect of the lesion. Following the procedure the clinical course was uneventful and the patient has remained symptom free. Anomalous coronary arteries are not immune to the From the Cardiology Section, Veterans Administration Medical Center, and Division of Cardiology, Department of Medicine, University of Miami School of Medicine, Miami, Florida.
Received May 2, 1990; revision accepted July 5 , 1990. Address reprint requests to Alan Schob, M.D., VA Medical Center, Medical Service ( I I I A ) , 1201 N.W. 16 Street, Miami, FL 33125.
40
Musial et al.
Fig. 1. Anomalous RCA in LAO-45" projection showing origin from left coronary cusp prior to PTCA.
Fig. 2. Anomalous RCA after PTCA.
effects of atherosclerotic disease [7]. The incidence of anomalous RCA in the population is approximately 0.28% [ 1,2]. A number of patients with these anomalies will present obstructive lesions suitable for dilation with PTCA. Because of the ostia and course of these anomalous vessels, cannulation and PTCA are a challenging endeavor. As in our case, the ostium is most commonly found anterior to the ostium of the left coronary artery in the left sinus of valsalva. The anomalous RCA takes an abrupt caudal anterior course between the great vessels before it continues a normal course into the right atrioventricular groove. The anterior location of the ostium in the left coronary cusp, the tortuous proximal portion, and the caudal anterior course of the artery pose specific problems not only for cannulation but also for guiding catheter backup during PTCA. To our knowledge experience with PTCA of anomalous RCA is limited to a single report [ 3 ] .In that case an FL4-G (USCI) guiding catheter was used with a 3 mm low-profile balloon dilation catheter over a 0.014 in flexible guidewire. In this case an 8F Amplatz left I soft-tip guiding catheter (Schneider) was used to cannulate the vessel. Seating of this guiding catheter however was barely adequate due to the aberrant position of the coronary ostium and the above-noted course of the artery. The backup necessary to permit passage of the larger-
diameter Trac plus balloon (Sci-Med) was insufficient. The extremely low profile (0.018 in.) dilating guidewire (Sci-Med DGW) required minimal backup support. It permitted adequate pre-dilatation of the artery to allow a larger, but still low-profile, ACE 3.0 mm (0.032 in.) balloon on a wire (Sci-Med) to cross the lesion and dilate to a satisfactory result. Our case illustrates the inherent difficulties in performing PTCA of lesions in anomalous coronary arteries. The use of trackable low-profile devices facilitates PTCA in those situations when backup support is at a minimum and may obviate the need to perform modification of guiding catheter tips [4-61 in order to accomplish PTCA.
REFERENCES I . Wilkins C, Betancourt B, Mathur V, Massumi A , Castro C , Garcia E, Hall R: Coronary artery anomalies. Tex Heart lnst J 15:166173, 1988. 2. Chaitman BR, Asperance J , Saltiel J , Bourassa MG: Clinical angiographic and hernodynarnic findings in patients with anomalous origin of the coronary arteries. Circulation 53: 122, 1976. 3. Mooss AN, Heintz MH: Percutaneous transluminal angioplasty of anomalous right coronary arteries. Cathet Cardiovasc Diagn 16: 16-18, 1989. 4. Swartz L, Aldridge H, Szarga C , Cseplo R: Percutaneous transluminal angioplasty of an anomalous left circumflex coronary artery
PTCA of Anomalous RCA arising from the right sinus of valsalva. Cathet Cardiovasc Diagn 8:623-627, 1982. 5. Bass T, Miller A, Rubin M, Stowers S , Perryman R: Transluminal angioplasty of anomalous coronary arteries. Am Heart J 1 12(3): 610-613, 1986. 6. Kimbiris D, Lo E, Iskandrian A: Percutaneous transluminal coro-
41
nary angioplasty of anomalous left circumflex coronary artery. Cathet Cardiovasc Diagn 13:407-410, 1987. 7. Click RL, Holmes DR, Vlietstra RE, Kosinski AS, Kronmal RA: Anomalous coronary arteries: Location degree of atherosclerosis and effect on survival. JACC 13(3):531-537, 1989.
Percutaneous Transluminal Coronary Angioplasty of Anomalous Right Coronary Artery Bart Musial, MD, Alan Schob, MD, Eduardo de Marchena, MD, and Kenneth M. Kessler, M D Coronary angioplasty of tortuous anomalous coronary arteries can be technically challenging. We describe a successful percutaneous transluminal coronary angioplasty (PTCA) of an anomalous right coronary artery after a failed previous attempt. The anatomic limitations of anomolous right coronary arteries and technical considerations for PTCA are discussed. Key words: coronary artery disease, PTCA, anatomic limitations,
Coronary artery anomalies are found in approximately 1% of the adult population undergoing cardiac catheterization. Certain anomalies may be associated with an increased incidence of obstructive coronary artery disease [l]. With the expanded use and technical advances of percutaneous transluminal coronary angioplasty (PTCA) in the treatment of coronary artery disease even patients with abnormal anatomy have become candidates for its application. There have been reports of PTCA of anomalous coronary arteries [3-61 but only 1 prior report of PTCA of an anomalous right coronary artery (RCA) [ 3 ] . The unusual origins and abberant courses of those arteries present problems in terms of backup support for PTCA. Occassionally , special guiding catheter modifications have been performed in order to obtain adequate support for these technically complicated and challenging angioplasties [4-61. We present a patient who underwent PTCA of a critically stenotic anomalous RCA after a previous unsuccessful attempt. A 64 yr-old black male with a 1 yr history of unstable angina underwent cardiac catheterization. Coronary angiography showed a 95% proximal stenosis of an anomalous RCA. The dominant RCA arose from the anterior aspect of the left sinus of valsalva and after a short (1 cm) initial straight segment abruptly took a caudal anterior course between the great vessels before returning to its normal distribution. After the sino-atrial branch a long irregular 95% stenosis was present. The left coronary artery exhibited only luminal irregularities. Mild posterior wall hypokinesia was noted on left ventriculography. PTCA using standard balloon over a wire technique through standard 8F modified Amplatz RCA, Judkins RCA, and multipurpose guiding catheters was attempted. Although the lesion was successfully crossed with a standard coronary guidewire, a low-profile bal0 1991 Wiley-Liss, Inc.
loon (USCI 2.0 mm profile plus) could not be advanced across the lesion due to lesion severity and poor backup from any of the guiding catheters. The patient was treated with antianginal medication with good initial control of symptoms. After 18 mo the patient returned with worsening symptoms. A thallium exercise stress test demonstrated a large area of reperfusion in the inferior wall. A cardiac catheterization revealed no significant change (Fig. 1). A second PTCA was attempted with different guiding and dilation catheters. The anomalous RCA was successfully cannulated with an 8F soft-tip Amplatz Left I guiding catheter (Schneider). A 0.014 guidewire (USCI Veriflex) was used to cross the stenosis but a 3.0 mm Trac plus PTCA balloon catheter (SciMed) was unable to cross lesion due to poor guiding catheter back-up. The guidewire and balloon were removed and a steerable 1.5 mm dilating guidewire (SciMed DGW) was then used to successfully pass and predilate the stenosis. Two inflations were performed at 10 atm for 2 min. This was exchanged for a 3.0 ACE PTCA balloon catheter (Sci-Med). The lesion was easily crossed and 3 inflations were performed at 8 atm. Angiograms revealed dilation of the 95% lesion (Fig. 1) to a 10% residual stenosis (Fig. 2). A small dissection was present in the proximal aspect of the lesion. Following the procedure the clinical course was uneventful and the patient has remained symptom free. Anomalous coronary arteries are not immune to the From the Cardiology Section, Veterans Administration Medical Center, and Division of Cardiology, Department of Medicine, University of Miami School of Medicine, Miami, Florida.
Received May 2, 1990; revision accepted July 5 , 1990. Address reprint requests to Alan Schob, M.D., VA Medical Center, Medical Service ( I I I A ) , 1201 N.W. 16 Street, Miami, FL 33125.
40
Musial et al.
Fig. 1. Anomalous RCA in LAO-45" projection showing origin from left coronary cusp prior to PTCA.
Fig. 2. Anomalous RCA after PTCA.
effects of atherosclerotic disease [7]. The incidence of anomalous RCA in the population is approximately 0.28% [ 1,2]. A number of patients with these anomalies will present obstructive lesions suitable for dilation with PTCA. Because of the ostia and course of these anomalous vessels, cannulation and PTCA are a challenging endeavor. As in our case, the ostium is most commonly found anterior to the ostium of the left coronary artery in the left sinus of valsalva. The anomalous RCA takes an abrupt caudal anterior course between the great vessels before it continues a normal course into the right atrioventricular groove. The anterior location of the ostium in the left coronary cusp, the tortuous proximal portion, and the caudal anterior course of the artery pose specific problems not only for cannulation but also for guiding catheter backup during PTCA. To our knowledge experience with PTCA of anomalous RCA is limited to a single report [ 3 ] .In that case an FL4-G (USCI) guiding catheter was used with a 3 mm low-profile balloon dilation catheter over a 0.014 in flexible guidewire. In this case an 8F Amplatz left I soft-tip guiding catheter (Schneider) was used to cannulate the vessel. Seating of this guiding catheter however was barely adequate due to the aberrant position of the coronary ostium and the above-noted course of the artery. The backup necessary to permit passage of the larger-
diameter Trac plus balloon (Sci-Med) was insufficient. The extremely low profile (0.018 in.) dilating guidewire (Sci-Med DGW) required minimal backup support. It permitted adequate pre-dilatation of the artery to allow a larger, but still low-profile, ACE 3.0 mm (0.032 in.) balloon on a wire (Sci-Med) to cross the lesion and dilate to a satisfactory result. Our case illustrates the inherent difficulties in performing PTCA of lesions in anomalous coronary arteries. The use of trackable low-profile devices facilitates PTCA in those situations when backup support is at a minimum and may obviate the need to perform modification of guiding catheter tips [4-61 in order to accomplish PTCA.
REFERENCES I . Wilkins C, Betancourt B, Mathur V, Massumi A , Castro C , Garcia E, Hall R: Coronary artery anomalies. Tex Heart lnst J 15:166173, 1988. 2. Chaitman BR, Asperance J , Saltiel J , Bourassa MG: Clinical angiographic and hernodynarnic findings in patients with anomalous origin of the coronary arteries. Circulation 53: 122, 1976. 3. Mooss AN, Heintz MH: Percutaneous transluminal angioplasty of anomalous right coronary arteries. Cathet Cardiovasc Diagn 16: 16-18, 1989. 4. Swartz L, Aldridge H, Szarga C , Cseplo R: Percutaneous transluminal angioplasty of an anomalous left circumflex coronary artery
PTCA of Anomalous RCA arising from the right sinus of valsalva. Cathet Cardiovasc Diagn 8:623-627, 1982. 5. Bass T, Miller A, Rubin M, Stowers S , Perryman R: Transluminal angioplasty of anomalous coronary arteries. Am Heart J 1 12(3): 610-613, 1986. 6. Kimbiris D, Lo E, Iskandrian A: Percutaneous transluminal coro-
41
nary angioplasty of anomalous left circumflex coronary artery. Cathet Cardiovasc Diagn 13:407-410, 1987. 7. Click RL, Holmes DR, Vlietstra RE, Kosinski AS, Kronmal RA: Anomalous coronary arteries: Location degree of atherosclerosis and effect on survival. JACC 13(3):531-537, 1989.
