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Left main coronary artery and ostial left anterior descending coronary artery stenting in a single coronary artery during NSTEMI. The OCT response
International Journal of Cardiology 184 (2015) 499–501
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Left main coronary artery and ostial left anterior descending coronary artery stenting in a single coronary artery during NSTEMI. The OCT response Dario Buccheri a,b, Bernardo Cortese a,⁎, Davide Piraino a,b, Pedro Silva Orrego a, Romano Seregni a a b
Interventional cardiology, Fatebenefratelli Hospital, Milan, Italy Department of cardiology, AOUP “P. Giaccone”, Palermo, Italy
a r t i c l e
i n f o
Article history: Received 21 January 2015 Accepted 1 March 2015 Available online 4 March 2015 Keywords: Single coronary artery Lipton classification Coronary anomalies NSTEMI OCT PCI
A 75-year-old woman with coronary artery risk factors including hypertension, hypercholesterolemia and impaired glucose tolerance was admitted at our institution for high risk non-ST elevation myocardial infarction (NSTEMI) (GRACE risk score: 171). The ECG showed negative Twaves in the antero-lateral leads and troponin was elevated (cTnT 67 ng/ml, n.v. 0–14 ng/ml). Given her high risk profile, the patient underwent urgent cardiac catheterization with a transradial approach. Coronary angiography revealed the absence of right coronary ostium in the right sinus of Valsalva and the presence of a single coronary artery arising from the left sinus. The territory of the right coronary artery was supplied by a distal branch of the left circumflex artery, configuring an anomaly also known like L1 type following the Lipton classification. Very few cases of this anomaly are described in the literature [1]. The left anterior descending artery (LAD) showed a calcific lesion with thrombotic subocclusion at the ostium, and a subsequent 90% stenosis (Fig. 1, A–B). The patient underwent percutaneous coronary intervention (PCI) of the left main coronary artery (LMCA) toward the LAD with manual thrombus aspiration followed by the implantation of two overlapped drug-eluting stents (DES) (3.0/28 mm and 2.5/18 mm Nobori, Terumo Corporation, Tokyo, Japan). We then postdilated the stents with a 3.0 mm noncompliant balloon and performed final kissing ⁎ Corresponding author at: Bastioni di Porta Nuova 21, 20121 Milano, Italy. E-mail address: [email protected] (B. Cortese).
http://dx.doi.org/10.1016/j.ijcard.2015.03.032 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
balloon toward LAD and left circumflex arteries (LCX) (Fig. 1, C–D–E). An intermediate lesion of mid LCX was left untreated. The patient was discharged 2 days later on medical therapy with aspirin and ticagrelor. After 1 year she underwent prescheduled control angiography that showed a good result of the previous PCI (Fig. 2, A), also confirmed by optical coherence tomography (OCT) analysis (Fig. 2, B–C–D). The patient underwent PCI with DES implantation of mid LCX that worsened. Discussion The prevalence of single coronary artery is between 0.024 and 0.066% [2] in the general population. Particularly, the type L1 of the Lipton's classification shows an incidence between 0 and 0.035%, constituting the 1.2% of all coronary anomalies [3] with a variable prognosis (no impairment of quality of life to symptomatic cardiac ischemia, congestive heart failure and sudden death), also depending on the presence and severity of the atherosclerotic burden. Despite the 2014 ESC/EACTS guidelines on myocardial revascularization [4] would suggest to perform coronary artery bypass graft in a patient with SYNTAX score of 35, the urgent clinical condition (high-risk NSTEMI with refractory angina) suggested to perform PCI as previously described [5]. We recognize that a restenosis would lead to dramatic consequences including possible sudden death. Thus, we decided to perform angiographic follow-up with OCT analysis, that showed good patency of coronary arteries with adequate strut coverage and stent apposition to the vessel wall. The OCT-guided follow-up allowed us to catch possible stent malapposition or incomplete coverage, allowing us to treat these complications in advance, or to tailor dual antiplatelet therapy. In conclusion, this is the first report of a patient with a single coronary artery arising from the left sinus of Valsalva (type L1 in Lipton's classification) with high risk NSTEMI undergoing PCI of an unprotected LMCA and LAD. This strategy with angiographic follow-up coadjuvated by OCT imaging seems a valuable alternative to coronary artery bypass grafting in patients with atherothrombotic complications of this rare coronary anomaly. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
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D. Buccheri et al. / International Journal of Cardiology 184 (2015) 499–501
Fig. 1. A) and B) Angiography of the right coronary artery (RCA) (star) arising from the distal left circumflex artery (LCX). Thrombotic subocclusion of ostial left anterior descending artery (LAD) (big arrow) and 90% stenosis of its middle portion (arrowhead). Mild stenosis (50%) at LCX middle tract (slim arrow). C) Left main coronary artery (LMCA)-proximal LAD stent implantation (big arrow). D) Final kissing balloon after two drug eluting stent (DES) implantation (big arrow in LAD, slim arrow in LCX). E) Final angiography.
Fig. 2. A) One-year angiographic follow-up shows the good result of previous PCI on LMCA-LAD, and after PCI of worsened middle LCX lesion (arrowhead). B) OCT analysis of middle LMCA with minimal stent area (MSA) of 14.2 mm2. C) OCT analysis of distal LMCA with good DES apposition and MSA of 17.9 mm2.
D. Buccheri et al. / International Journal of Cardiology 184 (2015) 499–501
References [1] L. Pourafkari, M. Taban, S. Ghaffari, Anomalous origin of right coronary artery from distal left circumflex artery: a case study and a review of its clinical significance, J. Cardiovasc. Thoracic Res. 6 (2014) 127–130. http://dx.doi.org/10.5681/jcvtr.2014. 027. [2] W. Desmet, J. Vanhaecke, M. Vrolix, F. Van De Werf, J. Piessens, J. Willems, H. De Geest, Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies, Eur. Heart J. 13 (1992) 1637–1640. [3] M.J. Lipton, W.H. Barry, I. Obrez, J.F. Silverman, L. Wexler, Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance, Radiology 130 (1979) 39–47.
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[4] S. Windecker, P. Kolh, F. Alfonso, J.P. Collet, J. Cremer, V. Falk, G. Filippatos, C. Hamm, S.J. Head, P. Jüni, A.P. Kappetein, A. Kastrati, J. Knuuti, U. Landmesser, G. Laufer, F.J. Neumann, D.J. Richter, P. Schauerte, M. Sousa Uva, G.G. Stefanini, D.P. Taggart, L. Torracca, M. Valgimigli, W. Wijns, A. Witkowski, 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for CardioThoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Eur. Heart J. 35 (2014) 2541–2619. http://dx.doi.org/10.1093/eurheartj/ehu278. [5] J.G. Tejada, F. Hernandez, I. Sanchez, R. Martin-Asenjo, Stenting of anomalous left main coronary artery arising from the right sinus of Valsalva: a case report, Int. J. Cardiol. 119 (2014) 266–267.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Left main coronary artery and ostial left anterior descending coronary artery stenting in a single coronary artery during NSTEMI. The OCT response Dario Buccheri a,b, Bernardo Cortese a,⁎, Davide Piraino a,b, Pedro Silva Orrego a, Romano Seregni a a b
Interventional cardiology, Fatebenefratelli Hospital, Milan, Italy Department of cardiology, AOUP “P. Giaccone”, Palermo, Italy
a r t i c l e
i n f o
Article history: Received 21 January 2015 Accepted 1 March 2015 Available online 4 March 2015 Keywords: Single coronary artery Lipton classification Coronary anomalies NSTEMI OCT PCI
A 75-year-old woman with coronary artery risk factors including hypertension, hypercholesterolemia and impaired glucose tolerance was admitted at our institution for high risk non-ST elevation myocardial infarction (NSTEMI) (GRACE risk score: 171). The ECG showed negative Twaves in the antero-lateral leads and troponin was elevated (cTnT 67 ng/ml, n.v. 0–14 ng/ml). Given her high risk profile, the patient underwent urgent cardiac catheterization with a transradial approach. Coronary angiography revealed the absence of right coronary ostium in the right sinus of Valsalva and the presence of a single coronary artery arising from the left sinus. The territory of the right coronary artery was supplied by a distal branch of the left circumflex artery, configuring an anomaly also known like L1 type following the Lipton classification. Very few cases of this anomaly are described in the literature [1]. The left anterior descending artery (LAD) showed a calcific lesion with thrombotic subocclusion at the ostium, and a subsequent 90% stenosis (Fig. 1, A–B). The patient underwent percutaneous coronary intervention (PCI) of the left main coronary artery (LMCA) toward the LAD with manual thrombus aspiration followed by the implantation of two overlapped drug-eluting stents (DES) (3.0/28 mm and 2.5/18 mm Nobori, Terumo Corporation, Tokyo, Japan). We then postdilated the stents with a 3.0 mm noncompliant balloon and performed final kissing ⁎ Corresponding author at: Bastioni di Porta Nuova 21, 20121 Milano, Italy. E-mail address: [email protected] (B. Cortese).
http://dx.doi.org/10.1016/j.ijcard.2015.03.032 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
balloon toward LAD and left circumflex arteries (LCX) (Fig. 1, C–D–E). An intermediate lesion of mid LCX was left untreated. The patient was discharged 2 days later on medical therapy with aspirin and ticagrelor. After 1 year she underwent prescheduled control angiography that showed a good result of the previous PCI (Fig. 2, A), also confirmed by optical coherence tomography (OCT) analysis (Fig. 2, B–C–D). The patient underwent PCI with DES implantation of mid LCX that worsened. Discussion The prevalence of single coronary artery is between 0.024 and 0.066% [2] in the general population. Particularly, the type L1 of the Lipton's classification shows an incidence between 0 and 0.035%, constituting the 1.2% of all coronary anomalies [3] with a variable prognosis (no impairment of quality of life to symptomatic cardiac ischemia, congestive heart failure and sudden death), also depending on the presence and severity of the atherosclerotic burden. Despite the 2014 ESC/EACTS guidelines on myocardial revascularization [4] would suggest to perform coronary artery bypass graft in a patient with SYNTAX score of 35, the urgent clinical condition (high-risk NSTEMI with refractory angina) suggested to perform PCI as previously described [5]. We recognize that a restenosis would lead to dramatic consequences including possible sudden death. Thus, we decided to perform angiographic follow-up with OCT analysis, that showed good patency of coronary arteries with adequate strut coverage and stent apposition to the vessel wall. The OCT-guided follow-up allowed us to catch possible stent malapposition or incomplete coverage, allowing us to treat these complications in advance, or to tailor dual antiplatelet therapy. In conclusion, this is the first report of a patient with a single coronary artery arising from the left sinus of Valsalva (type L1 in Lipton's classification) with high risk NSTEMI undergoing PCI of an unprotected LMCA and LAD. This strategy with angiographic follow-up coadjuvated by OCT imaging seems a valuable alternative to coronary artery bypass grafting in patients with atherothrombotic complications of this rare coronary anomaly. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
500
D. Buccheri et al. / International Journal of Cardiology 184 (2015) 499–501
Fig. 1. A) and B) Angiography of the right coronary artery (RCA) (star) arising from the distal left circumflex artery (LCX). Thrombotic subocclusion of ostial left anterior descending artery (LAD) (big arrow) and 90% stenosis of its middle portion (arrowhead). Mild stenosis (50%) at LCX middle tract (slim arrow). C) Left main coronary artery (LMCA)-proximal LAD stent implantation (big arrow). D) Final kissing balloon after two drug eluting stent (DES) implantation (big arrow in LAD, slim arrow in LCX). E) Final angiography.
Fig. 2. A) One-year angiographic follow-up shows the good result of previous PCI on LMCA-LAD, and after PCI of worsened middle LCX lesion (arrowhead). B) OCT analysis of middle LMCA with minimal stent area (MSA) of 14.2 mm2. C) OCT analysis of distal LMCA with good DES apposition and MSA of 17.9 mm2.
D. Buccheri et al. / International Journal of Cardiology 184 (2015) 499–501
References [1] L. Pourafkari, M. Taban, S. Ghaffari, Anomalous origin of right coronary artery from distal left circumflex artery: a case study and a review of its clinical significance, J. Cardiovasc. Thoracic Res. 6 (2014) 127–130. http://dx.doi.org/10.5681/jcvtr.2014. 027. [2] W. Desmet, J. Vanhaecke, M. Vrolix, F. Van De Werf, J. Piessens, J. Willems, H. De Geest, Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies, Eur. Heart J. 13 (1992) 1637–1640. [3] M.J. Lipton, W.H. Barry, I. Obrez, J.F. Silverman, L. Wexler, Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance, Radiology 130 (1979) 39–47.
501
[4] S. Windecker, P. Kolh, F. Alfonso, J.P. Collet, J. Cremer, V. Falk, G. Filippatos, C. Hamm, S.J. Head, P. Jüni, A.P. Kappetein, A. Kastrati, J. Knuuti, U. Landmesser, G. Laufer, F.J. Neumann, D.J. Richter, P. Schauerte, M. Sousa Uva, G.G. Stefanini, D.P. Taggart, L. Torracca, M. Valgimigli, W. Wijns, A. Witkowski, 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for CardioThoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Eur. Heart J. 35 (2014) 2541–2619. http://dx.doi.org/10.1093/eurheartj/ehu278. [5] J.G. Tejada, F. Hernandez, I. Sanchez, R. Martin-Asenjo, Stenting of anomalous left main coronary artery arising from the right sinus of Valsalva: a case report, Int. J. Cardiol. 119 (2014) 266–267.