- Email: [email protected]
Primary angioplasty for acute myocardial infarction in a patient with a solitary coronary ostium and a “superdominant” right coronary artery
International Journal of Cardiology 99 (2005) 473 – 476 www.elsevier.com/locate/ijcard
Letter to the Editor
Primary angioplasty for acute myocardial infarction in a patient with a solitary coronary ostium and a ‘‘superdominant’’ right coronary artery Giovanni Amoroso a,*, Efisia Monni a, Ugo Limbruno a, Maurizio Raugi b, Marco De Carlo a, Nicola Ciabatti a, Silvia Guideri a, AnnaSonia Petronio a, Mario Mariani a a
Cardiothoracic Department, University of Pisa, via Paradisa 2, Pisa 56124, Italy b Cardiology and Coronary Care Unit, General Hospital of Livorno, Italy Received 29 October 2003; accepted 18 November 2003 Available online 12 April 2004
Abstract Coronary artery anomalies (CAAs) are a rare angiographic finding, sometimes associated with acute coronary events. We report on a case of primary angioplasty for inferior acute myocardial infarction (AMI) in a 66-year-old woman with a solitary coronary ostium in the right Sinus of Valsalva and a ‘‘superdominant’’ right coronary artery. We also discuss two potential pitfalls of primary angioplasty: correct interpretation of coronary anatomy and approach to challenging lesions. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Primary angioplasty; Acute myocardial infarction; Radial; Coronary anomalies; Gpiibiiia inhibitors
1. Introduction The finding of coronary artery anomalies (CAAs) at coronary angiography ranges between 0.64% and 5.6%. Patients are mostly asymptomatic but acute myocardial infarction (AMI) can be a possible, yet uncommon, clinical presentation. In some cases, AMI is per se linked to CAAs , as in the case of coronary origin from the pulmonary artery, or of a single coronary artery, routing between the pulmonary artery and the aorta [1]. In other cases, AMI can still depend on superimposed coronary artery disease [2]. As primary percutaneous coronary intervention (PCI) is gaining favour as the treatment of choice for AMI [3], more CAAs are expected to be diagnosed and treated over time by PCI in the setting of acute myocardial infarction [4]. We present a case of primary PCI in a patient with a solitary coronary ostium and a ‘‘superdominant’’ right coronary artery.
2. Case report A 66-year-old woman with the diagnosis of inferior AMI was referred late in the night to our Cath Lab. * Corresponding author. Tel./fax: +39/050/995325. E-mail address: [email protected] (G. Amoroso). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.056
The patient, a previous smoker, known for mild hypercholesterolemia, had presented 2 h before to the Emergency Room of a peripheral hospital for intense epigastrial pain, asthenia, and neurovagal symptoms of recent onset (less than 1 h). Before any EKG was recorded, the patient went unconscious: EKG monitoring showed ventricular fibrillation, and the patient was successfully resumed to sinus rhythm by DC shock (200 J). The patient was also intubated until she completely recovered consciousness. At that time EKG showed ST-segment elevation ( c 2 mm) in leads II, III, aVF, with ST-segment depression in leads V1 to V4 (Fig. 1A). The patient received acetylsalicilic acid (ASA) 500 mg i.v., heparin 5000 UI i.v., amiodarone 300 mg i.v., atenolol 2.5 mg i.v., and was transferred to our Center for urgent catheterisation. At the time of arrival, the patient had still severe epigastrial pain, and showed a minor disturbance in spatiotemporal orientation. Patient was in sinus rhythm (70 bpm), and according to the medical staff of the ambulance had suffered for no ventricular arrhythmia during transportation. Blood pressure was 110/70 mm Hg. Coronary angiography was performed through right radial approach with a 6F guiding catheter (Radial, Boston Scientific, Maple Grove, MN). It was not possible to locate the left coronary ostium in the left sinus of Valsalva. Cannulation of the right coronary ostium in the right sinus of Valsalva showed a dominant
474
G. Amoroso et al. / International Journal of Cardiology 99 (2005) 473–476
Fig. 1. 12-leads EKG recorded at admission (A) and soon after primary PCI (B). Patient is in sinus rhythm. ST-segment elevation is present at admission in leads II, III, and aVF. ST-segment depression is present in leads V1 to V4. After PCI ST-segment alterations are completely reverted.
right coronary artery (RCA), which gave origin to a welldeveloped right posterior descending artery (R-PDA) and a long but subtle distal branch, with no evident stenosis. From the right coronary ostium also originated an anomalous left coronary artery (LCA) with posterior route to the aorta, which gave origin to a normal left anterior descending artery (LAD) and a short circumflex artery (Cx) (Fig. 2A – B), with no apparent stenosis. According to the anatomical classification of Lipton [5], we diagnosed a type R-II P of single coronary artery. No truncated or occluded coronary vessels or branches were visible. However, angiograms taken 10 min after the administration of a bolus of Abciximab (20 mg i.v.) revealed an anterograde, albeit poor, filling (TIMI 1) for some branches, arising from the distal portion of the RCA (Fig. 2). Due to its acute take-off angle, wiring of the distal RCA was only possible with an hydrophilic guidewire (PT Graphix, Boston Scientific), after temporary occlusion of the ostium of the R-PDA with an angioplasty balloon (Maverick2 2.5/20, Boston Scientific) (Fig. 2D). Distal RCA was reopened with a small balloon (Maverick2 2.5/ 20, Boston Scientific): a huge right posterolateral branch (RPL) and two marginal branches (MO) became visible, with good anterograde filling (TIMI 2 to 3). Distal RCA was then properly dilated with balloon (Maverick 4.0/40, Boston Scientific) (Fig. 3). Due to the satisfactory result of the procedure (stenosis < 20%, no dissections) and the acute take-off angle of distal RCA, no stenting was attempted. After the end of the procedure, patient referred an immediate relief from pain. EKG recorded soon after showed a complete resolution of ST-segment elevation in
leads II, III, aVF, and of ST-segment depression in leads V1 to V4 (Fig. 1B). Radial sheath was removed in the Cath Lab and a tight bandage was applied on the site of puncture, then the patient was moved to the local Coronary Care Unit. Abciximab (0.125 Ag kg 1 min 1) was infused for 6 h but then discontinued for hematuria. 2D-echocardiogram at 24 h showed a preserved left ventricular function (LV EF c 50%), with akinesia of the inferior apex. Patient was mobilised after 72 h and discharged on her sixth day in good physical conditions, under ASA, Ace inhibitors, betablockers, and statin treatment.
3. Discussion Primary PCI is progressively becoming the treatment of choice for AMI. A recent meta-analysis of all randomised studies has shown that primary PCI saves three lives more than thrombolysis for every 100 treated patients, and 5 patients more from major cardiovascular events [3]. Nevertheless, primary PCI can have some potential pitfalls. A correct interpretation of the anatomy of the coronary tree, given the lack of time required by the urgent procedure, can be one serious issue. In any individual, there are anatomical variations in the number, dimension, and distribution of coronary branches: when occlusion occurs at bifurcations and no collateral flow is present, infarct-related branches may go undetected [6]. CAAs represent a typical case of complex coronary anatomy, in which, in the acute setting, the attention of the operator can be driven elsewhere then to the occluded
G. Amoroso et al. / International Journal of Cardiology 99 (2005) 473–476
475
Fig. 2. Periprocedural coronary angiograms. A dominant right coronary artery (RCA), with a well-developed right posterior descending artery (R-PDA) and a distal branch originates from the right sinus of Valsalva are visible at admission. No stenosis or truncated vessels are detectable (A). From the same ostium also originates a left coronary artery (LCA) with posterior route to the aorta. LCA gives origin to a normal left anterior descending artery (LAD) and a short circumflex artery (Cx). No stenosis or truncated vessels are detectable on LCA (B). An anterograde, albeit poor, filling for a right posterolateral (R-PL) and two other distal branches (black tiny arrows) originating from the RCA, appears after the administration of Abciximab (bolus i.v.) (C) and wiring of distal RCA (D). White arrow indicates the site of coronary occlusion.
vessel. Among CAAs, single coronary artery has considered so far a rare finding (0.024%), but often associated with acute coronary events [1]. Either the solitary ostium being
located in the right or in the left Sinus of Valsalva, problems arise when the left or the right coronary artery has an intertruncal course (i.e. between the pulmonary artery and
Fig. 3. Final result. No residual stenosis or dissection is visible after ballooning. Right coronary artery (RCA) shows a TIMI-3 flow. A huge right posterolateral branch (R-PL) and two marginal branches (MO) are now visible on angiograms.
476
G. Amoroso et al. / International Journal of Cardiology 99 (2005) 473–476
the aorta). In that case an increased flow in the pulmonary artery and the aorta during exertion can cause a temporary pinching of the vessel, ultimately leading to AMI or sudden death. Schwarz et al. [7] have shown that, also when the anomalous coronary artery courses posterior to the aorta, external compression by the ascending aorta can cause an impairment of coronary flow. In our case, neither external compression nor atherosclerotic lesions were detectable at angiography onto the anomalous vessel (LCA). However, the contemporary presence of an anomalous LCA, and the absence of any collateral flow, could have disguised the missing of a relevant part of a ‘‘superdominant’’ RCA. Invasive approach to acute coronary syndromes and AMI is rapidly growing over time: we expect an increasing incidence of cases of difficult interpretation, such as single coronary arteries, and CAAs in general, during primary PCI. Abciximab is known to promote recanalization of occluded coronary arteries in nearly 1/3 of cases, when administered before primary PCI [8]. In our case, this was helpful for identifying the vessel to be reopened. A relevant problem in intervening on CAAs can be related to technical difficulties in approaching abnormal branches. It has been already proven that PCI procedural success changes according to the volume of procedures performed by operators and hospitals, with a lowest safety limit of 75 and 400 procedures per year, respectively. Primary PCI can require even more skill and experience than routine PCI in stable patients [9]. In our case, once identified the vessel to be treated (distal RCA), the most challenging issue was to wire it, due to its acute take-off angle from a bifurcation. The problem was overcome by temporarily occluding the other branch (R-PDA) with an angioplasty balloon. CAAs represent a very specific example of challenging anatomy for interventional cardiology, but such difficult situations can present also during PCI of otherwise-normal vessels. Of note, in our case the procedure was successfully accomplished through radial approach. When compared to femoral approach, cardiac catheterisation through the radial artery has demonstrated to reduce bleeding complications and to favour early discharge, in case of primary PCI [10]. In our experience, provided an adequate training of the operators and the usage of dedicated material, radial approach seems not a limitation for performing urgent and/or complex PCI.
In conclusion, we report a case of primary PCI in a patient with a solitary coronary ostium and a ‘‘superdominant’’ right coronary artery. This case highlights two possible pitfalls of PCI in the setting of AMI: difficulties in the interpretation of coronary anatomy, and in the approach to challenging lesions.
References [1] Rigatelli G, Rigatelli G. Coronary artery anomalies: what we know and what we have to learn. A proposal for a new clinical classification. Ital Heart J 2003;4:305 – 10. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126.595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990;21:28 – 40. [3] Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13 – 20. [4] Zweiker R, Luha O, Klein WW. Rescue percutaneous transluminal coronary angioplasty in a patient with a single coronary artery arising from the right sinus valsalvae: previously unreported scenario and review of literature. J Intern Med 2002;252:84 – 7. [5] Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130:39 – 47. [6] Bittl JA, Levin DC. Coronary arteriography. In: Braunwald E, editor. Heart Disease—A textbook of Cardiovascular Medicine. 5th ed. Philadelphia: WB Saunders; 1997. p. 240 – 72. [7] Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischemia by intracoronary Doppler and pressure measurements. Heart 1998;80: 307 – 11. [8] Montalescot G, Barragan P, Wittemberg O, Ecollan P, Elhadad S, Villain P, et al. Platelet Glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001;344: 1895 – 903. [9] Smith Jr SC, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001;37:2215 – 39. [10] Valsecchi O, Musumeci G, Vassileva A, Tespili M, Guagliumi G, Gavazzi A, Ferrazzi P. Safety, feasibility and efficacy of transradial primari angioplasty in patients with acute myocardial infarction. Ital Heart J 2003;4:329 – 34.
Letter to the Editor
Primary angioplasty for acute myocardial infarction in a patient with a solitary coronary ostium and a ‘‘superdominant’’ right coronary artery Giovanni Amoroso a,*, Efisia Monni a, Ugo Limbruno a, Maurizio Raugi b, Marco De Carlo a, Nicola Ciabatti a, Silvia Guideri a, AnnaSonia Petronio a, Mario Mariani a a
Cardiothoracic Department, University of Pisa, via Paradisa 2, Pisa 56124, Italy b Cardiology and Coronary Care Unit, General Hospital of Livorno, Italy Received 29 October 2003; accepted 18 November 2003 Available online 12 April 2004
Abstract Coronary artery anomalies (CAAs) are a rare angiographic finding, sometimes associated with acute coronary events. We report on a case of primary angioplasty for inferior acute myocardial infarction (AMI) in a 66-year-old woman with a solitary coronary ostium in the right Sinus of Valsalva and a ‘‘superdominant’’ right coronary artery. We also discuss two potential pitfalls of primary angioplasty: correct interpretation of coronary anatomy and approach to challenging lesions. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Primary angioplasty; Acute myocardial infarction; Radial; Coronary anomalies; Gpiibiiia inhibitors
1. Introduction The finding of coronary artery anomalies (CAAs) at coronary angiography ranges between 0.64% and 5.6%. Patients are mostly asymptomatic but acute myocardial infarction (AMI) can be a possible, yet uncommon, clinical presentation. In some cases, AMI is per se linked to CAAs , as in the case of coronary origin from the pulmonary artery, or of a single coronary artery, routing between the pulmonary artery and the aorta [1]. In other cases, AMI can still depend on superimposed coronary artery disease [2]. As primary percutaneous coronary intervention (PCI) is gaining favour as the treatment of choice for AMI [3], more CAAs are expected to be diagnosed and treated over time by PCI in the setting of acute myocardial infarction [4]. We present a case of primary PCI in a patient with a solitary coronary ostium and a ‘‘superdominant’’ right coronary artery.
2. Case report A 66-year-old woman with the diagnosis of inferior AMI was referred late in the night to our Cath Lab. * Corresponding author. Tel./fax: +39/050/995325. E-mail address: [email protected] (G. Amoroso). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.056
The patient, a previous smoker, known for mild hypercholesterolemia, had presented 2 h before to the Emergency Room of a peripheral hospital for intense epigastrial pain, asthenia, and neurovagal symptoms of recent onset (less than 1 h). Before any EKG was recorded, the patient went unconscious: EKG monitoring showed ventricular fibrillation, and the patient was successfully resumed to sinus rhythm by DC shock (200 J). The patient was also intubated until she completely recovered consciousness. At that time EKG showed ST-segment elevation ( c 2 mm) in leads II, III, aVF, with ST-segment depression in leads V1 to V4 (Fig. 1A). The patient received acetylsalicilic acid (ASA) 500 mg i.v., heparin 5000 UI i.v., amiodarone 300 mg i.v., atenolol 2.5 mg i.v., and was transferred to our Center for urgent catheterisation. At the time of arrival, the patient had still severe epigastrial pain, and showed a minor disturbance in spatiotemporal orientation. Patient was in sinus rhythm (70 bpm), and according to the medical staff of the ambulance had suffered for no ventricular arrhythmia during transportation. Blood pressure was 110/70 mm Hg. Coronary angiography was performed through right radial approach with a 6F guiding catheter (Radial, Boston Scientific, Maple Grove, MN). It was not possible to locate the left coronary ostium in the left sinus of Valsalva. Cannulation of the right coronary ostium in the right sinus of Valsalva showed a dominant
474
G. Amoroso et al. / International Journal of Cardiology 99 (2005) 473–476
Fig. 1. 12-leads EKG recorded at admission (A) and soon after primary PCI (B). Patient is in sinus rhythm. ST-segment elevation is present at admission in leads II, III, and aVF. ST-segment depression is present in leads V1 to V4. After PCI ST-segment alterations are completely reverted.
right coronary artery (RCA), which gave origin to a welldeveloped right posterior descending artery (R-PDA) and a long but subtle distal branch, with no evident stenosis. From the right coronary ostium also originated an anomalous left coronary artery (LCA) with posterior route to the aorta, which gave origin to a normal left anterior descending artery (LAD) and a short circumflex artery (Cx) (Fig. 2A – B), with no apparent stenosis. According to the anatomical classification of Lipton [5], we diagnosed a type R-II P of single coronary artery. No truncated or occluded coronary vessels or branches were visible. However, angiograms taken 10 min after the administration of a bolus of Abciximab (20 mg i.v.) revealed an anterograde, albeit poor, filling (TIMI 1) for some branches, arising from the distal portion of the RCA (Fig. 2). Due to its acute take-off angle, wiring of the distal RCA was only possible with an hydrophilic guidewire (PT Graphix, Boston Scientific), after temporary occlusion of the ostium of the R-PDA with an angioplasty balloon (Maverick2 2.5/20, Boston Scientific) (Fig. 2D). Distal RCA was reopened with a small balloon (Maverick2 2.5/ 20, Boston Scientific): a huge right posterolateral branch (RPL) and two marginal branches (MO) became visible, with good anterograde filling (TIMI 2 to 3). Distal RCA was then properly dilated with balloon (Maverick 4.0/40, Boston Scientific) (Fig. 3). Due to the satisfactory result of the procedure (stenosis < 20%, no dissections) and the acute take-off angle of distal RCA, no stenting was attempted. After the end of the procedure, patient referred an immediate relief from pain. EKG recorded soon after showed a complete resolution of ST-segment elevation in
leads II, III, aVF, and of ST-segment depression in leads V1 to V4 (Fig. 1B). Radial sheath was removed in the Cath Lab and a tight bandage was applied on the site of puncture, then the patient was moved to the local Coronary Care Unit. Abciximab (0.125 Ag kg 1 min 1) was infused for 6 h but then discontinued for hematuria. 2D-echocardiogram at 24 h showed a preserved left ventricular function (LV EF c 50%), with akinesia of the inferior apex. Patient was mobilised after 72 h and discharged on her sixth day in good physical conditions, under ASA, Ace inhibitors, betablockers, and statin treatment.
3. Discussion Primary PCI is progressively becoming the treatment of choice for AMI. A recent meta-analysis of all randomised studies has shown that primary PCI saves three lives more than thrombolysis for every 100 treated patients, and 5 patients more from major cardiovascular events [3]. Nevertheless, primary PCI can have some potential pitfalls. A correct interpretation of the anatomy of the coronary tree, given the lack of time required by the urgent procedure, can be one serious issue. In any individual, there are anatomical variations in the number, dimension, and distribution of coronary branches: when occlusion occurs at bifurcations and no collateral flow is present, infarct-related branches may go undetected [6]. CAAs represent a typical case of complex coronary anatomy, in which, in the acute setting, the attention of the operator can be driven elsewhere then to the occluded
G. Amoroso et al. / International Journal of Cardiology 99 (2005) 473–476
475
Fig. 2. Periprocedural coronary angiograms. A dominant right coronary artery (RCA), with a well-developed right posterior descending artery (R-PDA) and a distal branch originates from the right sinus of Valsalva are visible at admission. No stenosis or truncated vessels are detectable (A). From the same ostium also originates a left coronary artery (LCA) with posterior route to the aorta. LCA gives origin to a normal left anterior descending artery (LAD) and a short circumflex artery (Cx). No stenosis or truncated vessels are detectable on LCA (B). An anterograde, albeit poor, filling for a right posterolateral (R-PL) and two other distal branches (black tiny arrows) originating from the RCA, appears after the administration of Abciximab (bolus i.v.) (C) and wiring of distal RCA (D). White arrow indicates the site of coronary occlusion.
vessel. Among CAAs, single coronary artery has considered so far a rare finding (0.024%), but often associated with acute coronary events [1]. Either the solitary ostium being
located in the right or in the left Sinus of Valsalva, problems arise when the left or the right coronary artery has an intertruncal course (i.e. between the pulmonary artery and
Fig. 3. Final result. No residual stenosis or dissection is visible after ballooning. Right coronary artery (RCA) shows a TIMI-3 flow. A huge right posterolateral branch (R-PL) and two marginal branches (MO) are now visible on angiograms.
476
G. Amoroso et al. / International Journal of Cardiology 99 (2005) 473–476
the aorta). In that case an increased flow in the pulmonary artery and the aorta during exertion can cause a temporary pinching of the vessel, ultimately leading to AMI or sudden death. Schwarz et al. [7] have shown that, also when the anomalous coronary artery courses posterior to the aorta, external compression by the ascending aorta can cause an impairment of coronary flow. In our case, neither external compression nor atherosclerotic lesions were detectable at angiography onto the anomalous vessel (LCA). However, the contemporary presence of an anomalous LCA, and the absence of any collateral flow, could have disguised the missing of a relevant part of a ‘‘superdominant’’ RCA. Invasive approach to acute coronary syndromes and AMI is rapidly growing over time: we expect an increasing incidence of cases of difficult interpretation, such as single coronary arteries, and CAAs in general, during primary PCI. Abciximab is known to promote recanalization of occluded coronary arteries in nearly 1/3 of cases, when administered before primary PCI [8]. In our case, this was helpful for identifying the vessel to be reopened. A relevant problem in intervening on CAAs can be related to technical difficulties in approaching abnormal branches. It has been already proven that PCI procedural success changes according to the volume of procedures performed by operators and hospitals, with a lowest safety limit of 75 and 400 procedures per year, respectively. Primary PCI can require even more skill and experience than routine PCI in stable patients [9]. In our case, once identified the vessel to be treated (distal RCA), the most challenging issue was to wire it, due to its acute take-off angle from a bifurcation. The problem was overcome by temporarily occluding the other branch (R-PDA) with an angioplasty balloon. CAAs represent a very specific example of challenging anatomy for interventional cardiology, but such difficult situations can present also during PCI of otherwise-normal vessels. Of note, in our case the procedure was successfully accomplished through radial approach. When compared to femoral approach, cardiac catheterisation through the radial artery has demonstrated to reduce bleeding complications and to favour early discharge, in case of primary PCI [10]. In our experience, provided an adequate training of the operators and the usage of dedicated material, radial approach seems not a limitation for performing urgent and/or complex PCI.
In conclusion, we report a case of primary PCI in a patient with a solitary coronary ostium and a ‘‘superdominant’’ right coronary artery. This case highlights two possible pitfalls of PCI in the setting of AMI: difficulties in the interpretation of coronary anatomy, and in the approach to challenging lesions.
References [1] Rigatelli G, Rigatelli G. Coronary artery anomalies: what we know and what we have to learn. A proposal for a new clinical classification. Ital Heart J 2003;4:305 – 10. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126.595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990;21:28 – 40. [3] Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13 – 20. [4] Zweiker R, Luha O, Klein WW. Rescue percutaneous transluminal coronary angioplasty in a patient with a single coronary artery arising from the right sinus valsalvae: previously unreported scenario and review of literature. J Intern Med 2002;252:84 – 7. [5] Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130:39 – 47. [6] Bittl JA, Levin DC. Coronary arteriography. In: Braunwald E, editor. Heart Disease—A textbook of Cardiovascular Medicine. 5th ed. Philadelphia: WB Saunders; 1997. p. 240 – 72. [7] Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischemia by intracoronary Doppler and pressure measurements. Heart 1998;80: 307 – 11. [8] Montalescot G, Barragan P, Wittemberg O, Ecollan P, Elhadad S, Villain P, et al. Platelet Glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001;344: 1895 – 903. [9] Smith Jr SC, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001;37:2215 – 39. [10] Valsecchi O, Musumeci G, Vassileva A, Tespili M, Guagliumi G, Gavazzi A, Ferrazzi P. Safety, feasibility and efficacy of transradial primari angioplasty in patients with acute myocardial infarction. Ital Heart J 2003;4:329 – 34.