primary pci in anomalous coronary: wire first approach

Primary PCI in anomalous coronary: Wire first approach

Case Report

Primary PCI in anomalous coronary: Wire firstapproach

Abhijit Kulkarni a,*, B. Ramesh b

a Sr. Consultant, Department of Cardiology, Apollo Hospitals, Bangalore, Indiab Senior Consultant Cardiologist, Apollo Hospital, BG Road, Bangalore, India

a r t i c l e i n f o

Article history:

Received 5 October 2013

Accepted 2 May 2014

Available online xxx

Keywords:

Percutaneous coronary intervention

Acute coronary syndrome

Cardiac catheterization

Ostium

a b s t r a c t

Acute myocardial infarction in an anomalous coronary artery is an uncommon occurrence.

Elective (PCI) percutaneous coronary intervention in anomalous coronary in stable CAD is

challenging. We report a case of Primary PCI in an unstable patient (recurrent VT) with

anomalous coronary. Proximal portion of the occluded artery was delineated using non-

selective injection of dye with inverted left judkins directed towards the ostium. The

coronary guide wire was initially passed into the proximal lumen without guiding support

by skilled manipulation over which the left judkins was engaged. The catheter was

inverted when it engaged the anomalous ostium and the procedure was completed

successfully.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Case presentation

A 26-year-old smoker with no co morbidities was admitted to

our hospital with history of retrosternal chest pain with

sweating since 3 h. Electrocardiogram showed ST elevations

in inferior leads. He was administered heparin, nitrates and

antiplatelets and was taken up for cardiac catheterization.

The left anterior descending and left circumflex were

normal (Fig. 1). Right coronary artery was seen filling through

collaterals very faintly from the left side confirming the ECG

findings. Right coronary ostium could not be engaged with

Judkins Right catheter, No Torque Right or amplatz catheters

(Figs. 2 and 3).

Patient at this time became unstable with VT and was

electrically cardioverted multiple times before stabilizing.

Aortogram with pigtail performed at this stage showed faint

opacification of an occluded anomalous right coronary artery

arising near left coronary ostium in the late phase (Fig. 4).

A left Judkins was chosen to attempt to engage the ostium,

which was near the left ostium. The ostium and the proximal

portion which was occluded were clearly delineated by the

angiogram with inverted left judkins (Fig. 5). However, we

could not cannulate the ostium and the patient had ongoing

pain with two episodes of VT, which were cardioverted. This

time BMW floppy wire was passed into the occluded artery by

skilled manipulation while the catheter was still in the root

(without guiding catheter support) (Fig. 6) and then over the

wire the guiding catheter was engaged. Export thrombus

aspiration catheter was used to aspirate the thrombus.

2.0� 8mmTREK balloon (Fig. 7) was used and after predilation

distal artery was visualized (Fig. 8). The thrombotic lesion was

covered with 3 � 24 mm PROMUS ELEMENT stent and TIMI III

flow was achieved (Fig. 9). The patient stabilized electrically

* Tel.: þ91 9008022866 (mobile).E-mail address: [email protected] (A. Kulkarni).

Available online at www.sciencedirect.com

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a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e4

Please cite this article in press as: Kulkarni A, Ramesh B, Primary PCI in anomalous coronary: Wire first approach, ApolloMedicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.005

http://dx.doi.org/10.1016/j.apme.2014.05.0050976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

and was discharged uneventfully. Asymptomatic at one year

follow up.

2. Discussion

The occurrence of acute coronary syndrome in an anomalous

coronary requiring primary PCI is uncommon even in a high

volume interventional centre. A recent prospective angio-

graphic study reported the incidence of anomalous coronary

from opposite sinus as 1.07%, which included a 0.92% rate of

ectopic RCA originating from the left sinus and a 0.15% rate of

ectopic LCA arising from the right sinus.1

An anomalous RCA might originate from the anterior

aspect of the ascending aorta usually above the sinotubular

line (high anterior take-off), from the left sinus of valsalva

with a separate ostium from the left main coronary artery,

from the left main coronary artery (as a single coronary ar-

tery), or from the pulmonary trunk.2 Whether the anomalous

origin by itself predisposes the patient to accelerated athero-

sclerosis is a matter of debate. Hutchins et al3 suggested that

Fig. 1 e Normal left coronary circulation.

Fig. 2 e Unable to engage the right coronary with JR.

Fig. 3 e Unable to engage the right coronary with NTR.

Fig. 4 e Aortic root angiogram with pigtail.



the unusual angle of take-off and the more tortuous course of

the proximal portion of the anomalous coronary artery can

accelerate the rate of atherosclerosis.

Liu et al4 suggested that the junction point of the bound

portion and the free portion of an anomalous artery as it

wraps around the aorta is an area that is susceptible to lipid

accumulation.

Technical aspect of the procedure can be challenging

especially in an unstable patient as in our case. It is important

to identify the culprit artery based on integration of ECG, Echo

and angiogram reports so that search for the anomalous ar-

tery is hastened. It is suggested to do an aortogram early and

then choose catheters depending on position of anomalous

ostium. The catheters suggested in case of anomalous right

ostium are amplatz,5e7 voda6,7 or an undersized left judkins.8

Instead of “trial and error” for selection of catheter it is a

useful strategy to manipulate the wire inside the root with

guiding catheter directed towards the ostium so that wire

enters the culprit artery especially in the setting of primary

PCI. The guiding catheter can be engaged over the coronary

guide wire for the subsequent procedure. This saves time and

Fig. 5 e Occluded RCA delineated with JL catheter.

Fig. 6 e Skilled manipulation resulting in wire in the RCA

without guiding catheter support.

Fig. 7 e 2 3 8 mm TREK balloon dilatation.

Fig. 8 e Result of post balloon dilatation.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e4 3


can affect the outcome of the therapeutic procedure. To our

knowledge this technique of wiring the culprit artery without

engaging the ostium is not reported earlier.

3. Conclusion

The possibility of an anomalous coronary being the culprit

artery should be considered when selective cannulation is not

possible. Aortogram should be performed early to visualize

the artery. Information from electrocardiography and echo-

cardiogram is crucial and should be integrated to identify the

culprit artery and to look for the anomalous course. Long runs

during angiography to identify collaterals cannot be over-

emphasized. Skilled manipulation of the coronary guide wire

in the root to pass the wire into culprit artery and subsequent

engagement by guiding might save time compared with trial

and error method for selection of guiding catheter especially

in ACS situations. CT coronary angiogram is not a useful

method in ACS of anomalous coronary artery as it doesn’t

have a therapeutic role.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Angelini P. Coronary artery anomaliesecurrent clinicalissues: definitions, classification, incidence, clinicalrelevance, and treatment guidelines. Tex Heart Inst J. 2002;29:271e278.

2. Lee Jung-Jin, Kim Dae-Hyeok, Byun Sung-Su. A case of acutemyocardial infarction with the anomalous origin of the rightcoronary artery from the ascending aorta above the left sinusof valsalva and left coronary artery from the posterior sinus ofvalsalva. Yonsei Med J. 2009;50(1).

3. Hutchins GM, Miner MM, Boitnott JK. Vessel caliber andbranch-angle of human coronary artery branch-points. CircRes. 1976;38:572e576.

4. Liu LB, Richardson T, Taylor CB. Atherosclerotic occlusions inanomalous left circumflex coronary arteries. A report of 2unusual cases and a review of pertinent literature. ParoiArterielle. 1975;3:55e59.

5. Charney R, Spindola-Franco H, Grose R. Coronary angioplastyof anomalous right coronary arteries. Cathet Cardiovasc Diagn.1993;29:233e235.

6. Yip H, Chen MC, Wu CJ. Primary angioplasty in acute inferiormyocardial infarction with anomalous-origin right coronaryarteries as infarct-related arteries: Focus on anatomic andclinical features, outcomes, selection of guiding cathetersand management. J Invasive Cardiol. 2001;13:290e297.

7. Praharaj TK, Ray G. Percutaneous transluminal coronaryangioplasty with stenting of anomalous right coronaryartery originating from left sinus of valsalva using the Vodaguiding catheter: a report of two cases. Indian Heart J. 2001;53:79e82.

8. Ng W, Chow WH. Successful angioplasty and stenting ofanomalous right coronary artery using a 6 French Left Judkins#5guide catheter. J Invasive Cardiol. 2000;12:373e375.

Fig. 9 e End result with TIMI III flow.



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primary pci in anomalous coronary: wire first approach

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