|Year : 2018 | Volume
| Issue : 2 | Page : 155-157
Multivessel coronary intervention in a single coronary artery
Vinayakumar Desabandhu, Shiruvallur Ganapathy Shyam Lakshman
Department Of Cardiology, Government Medical College, Calicut, Kerala, India
|Date of Web Publication||13-Dec-2018|
Dr. Shiruvallur Ganapathy Shyam Lakshman
Department of Cardiology, Government Medical College, Calicut, Kerala
Source of Support: None, Conflict of Interest: None
Percutaneous coronary intervention forms the mainstay of treatment of coronary artery disease. Anomalous coronary artery origin is uncommon, and multivessel coronary intervention in such setting is a rarer entity. We report a case of multivessel coronary intervention in a patient with a single coronary artery from right coronary sinus bifurcating into left coronary artery and right coronary artery.
Keywords: Single coronary artery, anomalous coronary origin, percutaneous coronary intervention
|How to cite this article:|
Desabandhu V, Lakshman SS. Multivessel coronary intervention in a single coronary artery. Indian Heart J Interv 2018;1:155-7
|How to cite this URL:|
Desabandhu V, Lakshman SS. Multivessel coronary intervention in a single coronary artery. Indian Heart J Interv [serial online] 2018 [cited 2019 Sep 16];1:155-7. Available from: http://www.ihji.org/text.asp?2018/1/2/155/247444
| Introduction|| |
Anomalous origin of the coronary arteries is relatively uncommon and occurs in 0.3%–2.5% of patients. Most of them tend to be benign but occasionally may manifest with ischemia, syncope, myocardial infarction (MI), and sudden cardiac death (SCD). However, anomalous coronary system does not preclude them from predisposition to atherosclerosis. They may be detected by routine coronary angiography, and their detection warrants proper planning for coronary intervention in the setting of significant flow-limiting lesions.
| Case Report|| |
A 70-year-old lady, a case of infero-lateral wall MI lysed with streptokinase, was subjected to angiography as she had persisting rest pain. She was found to have a left coronary artery (LCA) arising as a single trunk from right sinus along with a right coronary artery (RCA) with normal course [Figure 1]A.
|Figure 1: (A) Anomalous origin of LCA from RCA. (B) Image showing discrete 90% disease in mid RCA and discrete 80% disease in mid LAD with course of LAD in anterior interventricular groove. (C) LCA and RCA wired for catheter stability|
Click here to view
LCA continued as a long left main coronary artery which passed between pulmonary artery and aorta before branching into left anterior descending (LAD) and left circumflex (LCX) artery. LAD was a small vessel and it coursed through anterior interventricular groove with discrete 90% disease in mid-LAD. RCA showed discrete 80% disease in mid-RCA and 90% in distal RCA [Figure 1]B; Video 1]. The single coronary artery (SCA) was engaged with a 7 French (F) Judkins right catheter. LCA and RCA were wired sequentially to ensure catheter stability [Figure 1]C. RCA was wired with Fielder XT–R (0.014”/0.010” × 180cm, Asahi Intecc, Aichi, Japan) and Finecross microcatheter (1.8F, 130cm; Terumo Medical, Somerset, New Jersey). Fielder XT–R was exchanged with Grand Slam extra support coronary guide wire (0.014” × 180cm, Asahi Intecc). RCA was dilated with Direct X balloon (2.00×10mm, MIV Therapeutics, Surat SEZ, India), and distal and proximal RCA was stented with sirolimus drug-eluting stent (DES) (3×16mm, Tetrilimus; SMT, Wakhariawadi, Surat, Gujarat, India and 3×16mm, M’Sure-S; Multimedics, Hicksville, NY, USA) [Figure 2]A and B; Video 2].
|Figure 2: (A) RCA wired and dilated with Direct X balloon. (B) RCA stented with sirolimus DES|
Click here to view
LAD was wired with Hi-Torque extra support Whisper ES (0.014” *190 cm, Abbott Vascular, Chicago, Illinois, USA) and was dilated with Direct X balloon (2.00×10mm, MIV Therapeutics) [Figure 3]A. LCA was stented with sirolimus DES (2.5×12mm, Yukon Choice PC; Translumina, Hechingen, Germany) [Figure 3]B; Video 3].
|Figure 3: (A) LAD dilated with Direct X balloon. (B) LCA stented with sirolimus DES|
Click here to view
Peri-procedural Thrombolysis in myocardial infarction III flow was achieved. No significant residual lesion was observed. The patient was clinically and hemodynamically stable, her post-procedural echo was normal and 1-month review was uneventful. After procedure, 128 slice coronary angiogram was taken to accurately assess the anatomy and patency of the stent [Figure 4]A and B].
|Figure 4: (A) Computed tomography (CT) coronary angiogram showing LAD in anterior interventricular groove with stent in situ. (B) CT coronary angiogram showing course of RCA|
Click here to view
| Discussion|| |
According to a case study by Angelini, anomalous origin of the LCA in the right sinus of Valsalva constitutes for 0.15% of all cases. Varying courses have been reported in literature, but inter-arterial course between aorta and pulmonary artery has been associated with SCD, especially after strenuous exercise. Phutane et al., in his recent study in 2018, described a rare manifestation of SCA with superdominant RCA with absent LCX and inter-arterial course of LCA.
Lipton et al. had described angiographic classification of SCA in his study in 1979. He proposed three angiographic groups of SCAs based on the site of origin and the anatomical distribution of the distribution of branches and the relationship of the branches with aorta and pulmonary artery. Yamanaka and Hobbs further subdivided these into five variants according to the relationship between the anomalous coronary arteries (ACAs) and aorta and pulmonary artery. This case falls into Lipton R-II-B of Lipton Classification as it runs between aorta and pulmonary artery and the common trunk gives rise to septal branches [Figure 1](a) and [Figure 4](a) and corresponds to the recent article published by Phutane et al.
Very few reports have described successful elective angioplasty of a single ACA in a patient with acute MI. Seth et al. and Bass et al. published a case of multivessel coronary intervention in SCA with abnormal origin of left main from RCA. Gupta et al. published a case report of successful percutaneous coronary intervention (PCI) of all the three coronary arteries arising from right sinus with a downward course of SCA and a difficult posterior course of LCX artery.
Considerations that need to be taken in such a case are proper selection and manipulation of guide catheters and guide wires and proper angulations at the tip of the wires. Proper care was taken in this case to ensure catheter stability to prevent retrograde dissection, which could involve right coronary ostium and prove fatal. In a nutshell, multivessel PCI in SCA is feasible under expertise with good procedural success. However, a proper understanding of the anatomy and judicious selection of appropriate hardware are of immense importance to minimize the risks that might have potentially serious hemodynamic consequences.
| Conclusion|| |
ACA with significant coronary artery disease is an uncommon entity, and percutaneous intervention is still a viable option.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Angelini P. Coronary artery anomalies: An entity in search of an identity. Circulation 2007;1:1296-305.
Barth CW 3rd, Roberts WC. Left main coronary artery originating from the right sinus of Valsalva and coursing between the aorta and pulmonary trunk. J Am Coll Cardiol 1986;1:366-73.
Phutane MV, Munde K, Shaikh S, Bansal NO. Single coronary artery from the right aortic sinus of Valsalva with super-dominant right coronary artery, anomalous interarterial course of the left coronary artery and absence of left circumflex artery: A case report. IHJ CVCR 2018.
Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: Diagnosis, angiographic classification, and clinical significance. Radiology 1979;1:39-47.
Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;1:28-40.
Seth A, Bhaskaran A, Gupta J, Bhatia ML. Multivessel coronary angioplasty with anomalous origin of the left main coronary artery. J Interv Cardiol 1995;1:359-63.
Bass TA, Miller AB, Rubin MR, Stowers SA, Perryman RA. Transluminal angioplasty of anomalous coronary arteries. Am Heart J 1986;1:610-3.
Gupta MD, Girish MP, Subhendu MS, Tyagi S. Percutaneous coronary intervention of all three coronary arteries originating from single coronary artery arising from the right sinus. Cardiovasc Interv Ther 2013;1:322-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]