Successful Coronary Intervention of Circumflex Artery Originating From an Anomalous ...
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`Home > Successful Coronary Intervention of Circumflex Artery Originating From an Anomalous Left Main Coronary Artery Using a Novel Support Catheter: A Case Report and
`Review of Literature
`
`Successful Coronary Intervention of Circumflex
`Artery Originating From an Anomalous Left Main
`Coronary Artery Using a Novel Support Catheter: A
`Case Report and Review of Literature
`
`By hmpeditor
`Created 12/01/2011 - 17:23
`December 2011 [1]
`Successful Coronary Intervention of Circumflex Artery Originating
`From an Anomalous Left Main Coronary Artery Using a Novel Support
`Catheter: A Case Report and Review of Literature
`
`• Thu, 12/1/11 - 5:23pm
`• 0 Comments
`•
`
`Section:
`New Techniques
`Issue Number: Volume 23 - Issue 12 - December 2011 [2]
`Author(s):
`
`Jimmy A. Thomas, MD1, Jigar Patel, MD2, Faisal Latif, MD1
`
`Abstract: Anomalous coronary arteries pose a great challenge during percutaneous intervention due to various
`technical factors. Inadequate guide support leads to significant obstacles for delivery of interventional devices to
`stenotic areas. Several methods have been proposed to overcome these obstacles. We present a novel technique
`where we used the Guideliner support catheter (Vascular Solutions, Inc.) to successfully intervene on a left
`circumflex coronary artery arising from a left main coronary artery anomalously arising from the right sinus of
`Valsalva.
`
`J INVASIVE CARDIOL 2011;23(12):536-539
`
`Key words: percutaneous coronary intervention, anomalous coronary artery, Guideliner
`
`______________________________________________
`
`[3]Congenital anomalies of the coronary arteries pose a challenge for coronary intervention due to
`multiple factors including the abnormal origin and the course of the artery. Challenges arise
`frequently from the lack of adequate guide support for delivery of devices to the target lesion. We
`present the case of a successful intervention performed on a critical stenosis in a left circumflex
`(LCX) artery that arose from an anomalous left main (LM) coronary artery originating from the right
`sinus of Valsalva. A novel technique was used that involved the use of the Guideliner support catheter (Vascular
`Solutions, Inc.).
`
`Case Report
`
`[4]A 65-year-old male with prior history of coronary artery bypass grafting (CABG) presented with
`non-ST segment elevation myocardial infarction. Five years prior to presentation, he had undergone
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`a 2-vessel CABG, with vein grafts to the right posterior descending artery (RPDA) and left anterior
`descending artery (LAD). The LM coronary artery was anomalous, originating from the right sinus of
`Valsalva. At the time of CABG, he only had severe disease in the right coronary artery (RCA), while
`the LAD was grafted only because it was thought to be [5]coming off of the LM at a very acute angle,
`which was felt to be a risk for future stenosis of the LAD. The LM was deemed not to be inter-
`arterial (running between the aorta and pulmonary artery). During the current admission, cardiac
`catheterization revealed that both vein grafts were totally occluded. RCA was totally occluded, with
`filling of the RPDA via collaterals from the left. Additionally, there was a critical 99% stenosis in the
`proximal LCX (Figure 1). The patient was referred for re-operation CABG. However, the surgeons only considered
`him a candidate for re-operation if the LM was coursing inter-arterially. Upon repeat cardiac catheterization and by
`placing a catheter in the pulmonary artery, it was confirmed that the LM actually coursed posterior to the aorta,
`and not inter-arterially (Figure 2). The LM had an intra-septal course and it gave off large septal branches before
`bifurcating; however, there was no systolic compression of the LM.
`
`[6]Therefore, we proceeded with percutaneous coronary intervention (PCI) of the subtotal occlusion
`of the LCX. A 6 Fr JR 5 guide catheter was used to engage the ostium of the LM. A Fielder wire
`(Abbott Vascular) was used to cross the critical stenosis in the LCX with the support of a 1.5 x 8 mm
`over-the-wire apex balloon (Boston Scientific Corporation). The Fielder wire was exchanged for a
`Grand Slam wire (Abbott Vascular). Then, the 1.5 mm balloon was used to perform angioplasty in
`the LCX. Attempts to advance a larger balloon or a stent were [7]unsuccessful, as the guide catheter
`continued to disengage from the LM, resulting in pulling back of the guidewire (Figure 3). At this
`point, we decided to use a 6 Fr GuideLiner catheter (Vascular Solutions, Inc.) for additional support.
`The GuideLiner catheter was placed in the distal LM immediately proximal to its bifurcation (Figure
`4). Subsequently, we were able to deliver a 2.5 x 12 mm Quantum balloon (Boston Scientific
`Corporation) to the stenosis without difficulty, which was used to perform angioplasty. Finally, a 2.75 x 15 mm
`Promus drug-eluting stent (Boston Scientific Corporation) was deployed at 13 atm. Final angiography revealed
`TIMI 3 flow without residual stenosis or dissection (Figure 5). Notably, once the GuideLiner catheter was
`positioned in the distal LM, not only was there excellent guiding catheter support and much easier advancement
`of interventional devices into the stenosis, but the quality of angiography improved due to improved ability to inject
`contrast directly into the distal LM. The patient continues to do well almost a year after the procedure.
`
`Discussion
`
`Anomalous coronary arteries. Normal coronary artery anatomy is characterized by the origins of the RCA and
`left coronary artery (LCA) from ostia from the respective sinuses of Valsalva in the aortic root. Congenital
`anomalies of the coronary arteries occur either in isolation as primary anomalies or as secondary anomalies in
`association with other congenital disease.1 Primary congenital anomalies of the coronary arteries are rather rare.
`Reports of their incidence vary from 0.3-1.6% in various case series.2 They are of the following types: a) ectopic
`origin from the aortic sinus; b) stenosis of coronary arteries; c) absence of a coronary artery; d) anomalous origin
`of the LCA or RCA from the pulmonary artery; and e) congenital coronary artery fistula.1 Our patient had a primary
`congenital coronary anomaly as no other associated anomaly was identified.
`
`The most common anomaly is an LCX arising from the RCA, with an incidence as high as 50% of all coronary
`anomalies in one case series.3 An anomalous LM is among the rarest, with an incidence of 2.5-12% of all
`congenital coronary arterial anomalies, and is commonly associated with other congenital defects.4,5 However, in
`our patient, origin of the LM from the right sinus occurred in isolation.
`
`When the LM originates from the right sinus of Valsalva, it may be classified into one of four types: a) the LM
`passes between the aorta and pulmonary trunk, posteriorly and adjacent to the pulmonary trunk; b) the LM passes
`anteriorly over the right ventricular outflow tract; c) the LM courses along the crista supraventricularis
`intramyocardially or subendocardially, surfacing in the proximal interventricular sulcus; and d) the LM may rise to
`the right of the RCA and pass posteriorly to the aortic root or anterior to the pulmonary trunk.1 In our patient, the
`LM coursed posterior to the aorta (Figure 2).
`
`Anomalous LM arising from the right sinus of Valsalva having an intraseptal course is an extremely rare and
`potentially fatal congenital anomaly, with a reported incidence of 0.017% in one large series.6-8 The septal course
`of the LM has also been referred to as “intra-myocardial” or “tunneled” anomalous origin.9,10 The angulation of the
`artery after its origin from the aortic sinus determines the risk of occlusion. An acute angulation results in a slit-like
`ostium. With increased cardiac output and the accompanying dilation of the aortic root, this slit-like ostium narrows
`even further, resulting in ischemia. Acute myocardial infarction and even sudden death have been reported both in
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`cases where the anomalous artery coursed in between the great vessels and in those where it coursed anterior to
`the pulmonary trunk or posterior to the aorta.11,12
`
`Regardless of the course of the coronary arteries, recognition of coronary anomalies is important prior to cardiac
`surgery as the accidental incision or exclusion of an anomalous vessel from perfusion during bypass can cause
`grave problems.13 Accurate identification of the origin and course of anomalous coronary arteries can prove
`decisive in the successful completion of interventional procedures, helping in the selection of appropriate guide
`catheters, guidewires and balloons.4
`
`Technical difficulties in procedures on anomalous coronary arteries. PCI of anomalous coronary arteries
`poses several technical challenges. When a single coronary artery is given off from the aortic sinus which then
`bifurcates into RCA and LCA from a common ostium, the coronary arteries have an unusual direction and a
`tortuous angle making cannulation difficult. A potential complication of PCI in such cases is dissection that occurs
`with advancing the equipment. The retrograde extension of such a dissection may involve the origins of the LCA
`and RCA, with potentially catastrophic consequences.14
`
`PCI in anomalous coronary arteries: proposed methods. In view of the increased technical difficulty of PCI in
`anomalous arteries, selection of the appropriate equipment assumes greater importance, ranging from
`successfully engaging the ostium of the anomalous coronary artery with adequate support to advance
`interventional devices and ultimately, concluding the procedure with minimal exposure to contrast agents and
`radiation. Various angiographic features such as aortic root dimensions, ostial configuration, takeoff angle and
`initial trajectory of the anomalous vessel, as well as the type of procedure planned, are factors that influence the
`selection of guide catheters.15 Another major hurdle experienced during PCI of extensively calcified or tortuous
`arteries is the lack of adequate back-up support from the guiding catheter, when advancing interventional devices.
`Use of buddy wires has been reported.16 Our case provides a novel technique that is an alternative to those
`previously described.
`
`The GuideLiner system is a flexible coaxial catheter that is intended to be used in conjunction with any standard
`guide catheter and works as a “mother and child” system. It provides additional back-up support and coaxial
`alignment to access discrete regions of coronary vasculature and to facilitate delivery of devices as in our case. It
`has the convenience of rapid exchange with the ability to use standard length guidewires, balloons, or stents.
`However, it is important to avoid the use of the GuideLiner system in vessels that are less than 2.5 mm in
`diameter. A few recent cases have reported the use of GuideLiner support catheter for successful intervention of
`very tortuous or rigid (owing to prior stenting or extensive calcification) coronary arteries, mainly for distal delivery
`of balloons or stents.17 There has been a reported case of PCI of an anomalous LM in the setting of acute
`myocardial infarction.18 To our knowledge, this is the first report where a GuideLiner catheter has been
`successfully used for PCI of a very rare variety of anomalous LM coronary artery.
`
`Our technique has certain advantages over the ones previously used. For instance, in comparison to the buddy
`wire technique, use of the GuideLiner system results in avoidance of rewiring of the target artery, which requires
`having to cross the tight stenosis with another wire, which can be difficult to achieve and also worsens ischemia or
`even worse, causes a dissection. Furthermore, lack of support from the guide catheter would also be an obstacle
`to advancement of a buddy wire as well, like in our case, where trying to advance a buddy wire with poor support
`from the JR5 catheter would have been difficult to achieve. We even experienced difficulty in trying to get the first
`wire across the critical stenosis in the circumflex artery. Additionally, due to the fact that with a GuideLiner,
`injection of contrast is closer to the site of intervention, contrast exposure would be reduced. The GuideLiner
`system can be advanced over the wire as simple as a monorail balloon, and does not involve manipulation of two
`guide catheters, as would be required in the actual “mother and child” technique.
`
`Conclusion
`
`Anomalous LM coronary arteries are extremely rare and percutaneous revascularization can be a great challenge
`because of the lack of support from the most commonly used guide catheters. Our use of the GuideLiner catheter
`for revascularization of the LCX arising from an anomalous LM coronary artery is a novel technique that can be
`utilized in similar cases.
`
`References
`
`1. Hauser M. Congenital anomalies of the coronary arteries. Heart. 2005;91(9):1240-1245.
`2. Alexander RW, Griffith GC. Anomalies of the coronary arteries and their clinical significance. Circulation.
`1956;14(5):800-805.
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`3. Kimbiris D, Iskandrian AS, Segal BL, Bemis CE. Anomalous aortic origin of coronary arteries. Circulation.
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`sinus of Valsalva with myocardial infarction. J Thorac Cardiovasc Surg. 1978;75(2):282-285.
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`13. Longenecker CG, Reemtsma K, Creech O Jr. Surgical implications of single coronary artery. A review and
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`2006;18(5):E154-E156.
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`right coronary arteries. J Interv Cardiol. 2009;22(3):234-239.
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`
`______________________________________________
`
`From the 1Department of Internal Medicine, and 2Cardiovascular Section, Department of Internal Medicine,
`University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
`Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of
`Interest. The authors report no conflicts of interest regarding the content herein.
`Manuscript submitted April 20, 2011, provisional acceptance given June 27, 2011, final version accepted August
`17, 2011.
`Address for correspondence: Faisal Latif, MD, FACC, FSCAI, Assistant Professor of Medicine, Cardiovascular
`Section, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd., WP#3010, Oklahoma City,
`OK 73104. Email: faisal-latif@ouhsc.edu [8]
`
`[9]
`
`[10]
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`Source URL: http://www.invasivecardiology.com/articles/successful-coronary-intervention-circumflex-artery-originating-anomalous-left-
`main-coronary
`
`New Techniques
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`Links:
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`[2] http://www.invasivecardiology.com/content/volume-23-issue-12-december-2011
`[3] http://www.invasivecardiology.com/files/10%20NewTech_pg536_Fig%201.png
`[4] http://www.invasivecardiology.com/files/10%20NewTech_pg536_Fig%202.png
`[5] http://www.invasivecardiology.com/files/10%20NewTech_pg536_Fig%203.png
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`[7] http://www.invasivecardiology.com/files/10%20NewTech_pg536_Fig%205.png
`[8] mailto:faisal-latif@ouhsc.edu
`[9] http://www.invasivecardiology.com/printmail/3082
`[10] http://www.invasivecardiology.com/print/3082
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