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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 166-168

Percutaneous coronary intervention of an anomalous right coronary artery originating from ascending aorta


1 Department of Cardiology Max Super Speciality Hospital, Patparganj and Vaishali, Delhi, India
2 Department of Cardiology and Radiodiagnosis, Max Super Speciality Hospital, Patparganj and Vaishali, Delhi, India

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Samir Kubba
420-B, Pocket 2, Mayur Vihar, Phase-1, Delhi 110091
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_25_18

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  Abstract 

Anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is a very rare coronary anomaly, which can pose extreme difficulties for the operator, especially in the setting of an acute myocardial infarction. Herein, we describe a patient with this very rare anomaly in whom computed tomography coronary angiographic guidance was used to identify its presence and perform successful angioplasty in the setting of an inferior wall myocardial infarction complicated by 2:1 atrioventricular block.

Keywords: Anomalous coronaries, computed tomography coronary angiography, myocardial infarction


How to cite this article:
Kubba S, Pandey AK, Gupta VK, Gupta S. Percutaneous coronary intervention of an anomalous right coronary artery originating from ascending aorta. Indian Heart J Interv 2018;1:166-8

How to cite this URL:
Kubba S, Pandey AK, Gupta VK, Gupta S. Percutaneous coronary intervention of an anomalous right coronary artery originating from ascending aorta. Indian Heart J Interv [serial online] 2018 [cited 2019 Oct 16];1:166-8. Available from: http://www.ihji.org/text.asp?2018/1/2/166/247449




  Introduction Top


Anomalous coronary arteries can be challenging, especially in the setting of an acute coronary syndrome. Here, the interventionist needs to be quick and accurate, simultaneously minimizing the contrast load. It is helpful to be aware of different possible anomalies.

We describe a rare anomalous right coronary artery (RCA) in a patient with inferior wall myocardial infarction (IWMI) complicated by 2:1 atrioventricular (AV) block.


  Case Report Top


A 53-year-old man, who was a chronic smoker, presented with IWMI and 2:1 AV block with a history of chest pain and syncope 5 days back in a hemodynamically stable condition. Echocardiogram revealed regional wall motion abnormality in RCA territory. The left ventricular ejection fraction was 45% with mild mitral regurgitation.

A temporary pacemaker was implanted via the right femoral vein approach and angiogram was carried out. The left system showed proximal 70% stenosis in the left anterior descending (LAD) artery with RCA showing retrograde filling via collaterals from the left system. However, the RCA could not be hooked despite repeated attempts with various catheters. As the procedure had prolonged with a significant volume of contrast having been injected, we aborted the attempt with a plan to hydrate the patient and perform computed tomography (CT) coronary angiography. Although an aortogram could have helped to delineate the origin of RCA, we decided against it to limit radiation exposure and contrast volume. With favorable factors such as delayed presentation, hemodynamic stability, and availability of CT coronary angiography, we chose to electively plan the procedure the next day. CT coronary angiography reduces the morbidity risk in these patients and decreases overall radiation exposure in comparison to quantitative coronary angiogram, especially in difficult clinical scenario such as ours where we had already failed to hook the RCA despite using multiple catheters. The CT angiogram showed the high aortocoronary takeoff of the RCA and its spatial relationships with the heart and great vessels. It revealed the anomalous high and posterior origin of the RCA from the ascending aorta, approximately 18mm from the sinotubular junction, above the left sinus of Valsalva [Figure 1]A and B]. It was occluded proximally, passing between the aorta and the pulmonary artery. Using this valuable information, we were successful in hooking the RCA with amplatz left 1 (AL1) 6 French guiding catheter, high and hanging in the aorta [Figure 2]A in the first go itself, without using much of contrast. The procedure was successfully completed using two overlapping Xience Alpine drug-eluting stents (®Abbott., 3200 Lakeside Dr., Santa Clara, CA 95054, USA) measuring 2.75×38mm and 3×33mm in mid-to-distal RCA and proximal-to-mid RCA, respectively, restoring thrombolysis in myocardial infarction 3 flow in the system [Figure 2]B. The patient had an uneventful recovery, reverting to normal sinus rhythm after 2 days.
Figure 1: (A) CT coronary angiography (sagittal view) showing anomalous high and posterior origin of the RCA from the ascending aorta (red arrow) above the left sinus of Valsalva and coursing between the pulmonary artery and ascending aorta. (B) Volume-rendered image of the CT coronary angiogram in the left anterior oblique cranial view showing the anomalous origin

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,
Figure 2: (A) Selective coronary angiogram of the anomalous RCA using AL1 guide catheter. (B) Post-percutaneous transluminal angioplasty coronary angiogram showing thrombolysis in myocardial infarction (TIMI) 3 flow in the RCA after implantation of two overlapping drug-eluting stents

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  Discussion Top


An anomalous origin of the RCA from ascending aorta above the left sinus of Valsalva is an extremely rare coronary anomaly, this was first described by Yans et al.[1] Till date, few reported cases of the RCA originating from ascending aorta above the sinotubular junction plane are available. Sarkar et al.[2] reported a 0.006% prevalence of this rare anomaly, comprising 2.1% of all anomalously originating coronary arteries. Only four cases in the setting of an acute myocardial infarction (MI) have been described.[3],[4],[5],[6] The increasing use of CT coronary angiography has increased the probability of diagnosing such anomalous coronaries in the patients being screened. Mahajan et al.[7] reported a 55-year-old woman, asymptomatic, hypertensive, with a family history of coronary artery disease, who underwent a screening CT coronary angiogram revealing anomalous origin of RCA, 1cm above the left coronary sinus from the ascending aorta. The artery traversed between pulmonary trunk and aorta before following its normal course.[6] Venkatesan et al.[8] reported a 55-year-old man with an invasive coronary angiogram for unstable angina where mid-LAD showed critical stenosis (90%), but RCA could not be hooked despite using multiple catheters.[7] The reason was an extremely high origin of the RCA from ascending aorta on the posterior aspect with mid-RCA showing tubular lesion of 50%–60% severity (observed on an ascending aortogram via pigtail catheter). However, the severity of such a lesion can never be fully assessed without selective intubation. Thus, CT coronary angiography is a useful tool in such situations, providing the precise anatomic location of the anomaly and its spatial relation with the great vessels. This enables the operator to plan the intervention, choose appropriate guide catheter, and understand the long-term implications of the abnormal origin and course, as was observed in our case. However, in acute situations with hemodynamic instability, this may not be possible; hence, aortography may be considered the default strategy.

Such an anomaly is an interventional challenge with the RCA being difficult to engage because of the lack of good point of wall support or a slit-like orifice in the initial intra-aortic course. Invariably, such an aberrant RCA runs an anterior course, traversing between pulmonary artery and aorta. An anomalous anatomy could also predispose to accelerated atherosclerosis in the proximal portion, possibly, because of systolic compression of the aberrant artery between the two great vessels proximally, as well as the high takeoff with lateral displacement kinking the vessel. Thus, it may have clinical consequences such as angina pectoris, MI, syncope, and sudden death. Clinically, however, an angiographic documentation of anomalous coronary anatomy has not led to any effective or widely agreed treatment recommendations thus far.

Other than complicating the atherosclerotic process, such an anomaly also complicates management as was observed in our case. We failed to hook the anomalous vessel despite multiple attempts. Kherada et al.[6] had described the use of a left coronary bypass catheter, which was designed to hook left coronary venous bypass grafts, its tip having a 90-degree bend and a 70-degree secondary bend. Other reports have described the use of extra back up (EBU) 4.5 6F and AL1 guides to hook anomalous RCA.[4],[5]

We report this case to raise awareness about the possibility of encountering such anomalies in an emergency setting. Although it is hard to make a definitive recommendation, we propose that AL1, AL2, EBU, and multipurpose catheters could be advisable to start with, moving on to other approaches as discussed. Though our patient is well, 9 months after percutaneous coronary intervention (PCI), the long-term outcome in such patients is unpredictable, given the anatomic and physiological challenges discussed above. Before PCI, CT-guided information is helpful in selective cannulation and intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yans J, Kumar SP, Kwatra M. Anomalous origin of the right coronary artery above the left sinus of Valsalva. Cathet Cardiovasc Diagn 1978;1:407-12.  Back to cited text no. 1
    
2.
Sarkar K, Sharma SK, Kini AS. Catheter selection for coronary angiography and intervention in anomalous right coronary arteries. J Interv Cardiol 2009;1:234-9.  Back to cited text no. 2
    
3.
Ceyhan C, Tekten T, Onbasili AO. Primary percutaneous coronary intervention of anomalous origin of right coronary artery above the left sinus of Valsalva in a case with acute myocardial infarction. Coronary anomalies and myocardial infarction. Int J Cardiovasc Imaging 2004;1:293-7.  Back to cited text no. 3
    
4.
Jin SA, Seong SW, Kim SS, Lee YD, Choi UL, Choi SW, et al. Successful percutaneous coronary intervention in an anomalous origin of the right coronary artery from the ascending aorta above the left sinus of the Valsalva. Korean Circ J 2012;1:497-500.  Back to cited text no. 4
    
5.
Lee JJ, Kim DH, Byun SS, Choi WG, Lee CW, Yi SM, et al. A case of acute myocardial infarction with the anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva and left coronary artery from the posterior sinus of Valsalva. Yonsei Med J 2009;1:164-8.  Back to cited text no. 5
    
6.
Kherada N, Singla S, Gowani SA, Gallarello F, Beohar N. Anomalous right coronary artery arising from the ascending aorta above the left sinus of Valsalva in the setting of acute inferior ST elevation myocardial infarction: Unique challenges and literature review. Int J Clin Cardiol 1:31. 10.23937/2378-2951/1410031. Available from https://clinmedjournals.org/articles/ijcc/ijcc-2-031.php?jid=ijcc. Last accessed 29th October, 2018.  Back to cited text no. 6
    
7.
Mahajan D, Agnihotri G, Brar R. Anomalous origin of right coronary artery: An anatomico-clinical perspective of 2 cases. Acta Inform Med 2012;1:56-7.  Back to cited text no. 7
    
8.
Venkatesan K, Ravi MS, Palanisamy G, Balajipandian. Extremely rare high origin of right coronary artery from ascending aorta—A case report. J Indian Coll Cardiol 2016;1:106-7.  Back to cited text no. 8
    


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