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Rotational Atherectomy and Simultaneous Kissing Stenting of a Bifurcation Stenosis of Left Anterior Descending and Anomalous Right Coronary Arteries
CASE REPORT
Case Report
Rotational Atherectomy and Simultaneous Kissing Stenting of a Bifurcation Stenosis of Left Anterior Descending and Anomalous Right Coronary Arteries Paul K. Das, MD ∗ and Ian T. Meredith, PhD Cardiovascular Research Centre, Monash Medical Centre, Melbourne, Australia
Intervention to anomalous coronaries can present specific challenges: non-standard guide catheters may be required to provide adequate access and support, the course of the arteries can be tortuous with sharp angulations, and they may subtend a critical area of myocardium. We present the first report of percutaneous coronary intervention to the bifurcation of an anomalous right coronary artery arising from the left anterior descending artery. This lesion contained a high burden of calcification, which required rotational atherectomy of the left anterior descending artery before kissing stenting of the bifurcation. (Heart, Lung and Circulation 2006;15:342–345) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Coronary angioplasty; Rotational atherectomy; Coronary vessel anomalies
Case Report
A
71-year-old man was referred for coronary angiography. He had insulin dependant type II diabetes, hypertension and hiatus hernia. He had experienced intermittent chest pain for several years, which had recently increased in frequency. Gastroscopy was normal. Coronary angiography was performed using a 6 French Judkins L4 catheter. This demonstrated a single coronary artery of large calibre arising from the left coronary cusp following the normal course of the left main stem and left anterior descending artery (LAD). The left circumflex (LCX) arose from the main stem in the normal way and was a large, dominant vessel. The right coronary artery (RCA) was a smaller vessel which arose from the proximal LAD opposite the first septal branch at approximately 70◦ (Fig. 1). It passed anteriorly across the epicardial surface of the right ventricular outflow tract before entering the right atrioventricular groove, giving rise to a left ventricular branch. There was calcification of the proximal LAD and a calcified tubular 70–80% stenosis at the bifurcation of the Received 14 December 2005; accepted 28 March 2006; available online 12 May 2006 ∗
Correspondence to: Cardiovascular Research Centre, Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168, Australia. Tel.: +61 3 9594 4547; fax: +61 3 9594 4307. E-mail address: [email protected] (P.K. Das).
anomalous RCA (Fig. 2A and B). The LAD was of smaller calibre beyond the bifurcation. The RCA itself had calcified ostial and proximal 80% stenosis (Fig. 1). The circumflex had only minor irregularities. An aortogram showed no evidence of a separate RCA origin. Left ventricular ejection fraction was normal. After discussion at a joint surgical case conference, we elected to perform angioplasty and stenting to both branches of the bifurcation. We commenced with rotational atherectomy to reduce the burden of calcium in the lesion and assist stent passage into the sharply angulated ostium of the RCA. The patient was given pre-loading doses of aspirin 300 mg, clopidogrel 600 mg and intravenous heparin 70 units/kg. A temporary pacing wire was placed in the right ventricle. The left main stem was engaged with a 7French Extra Back Up 4.0 guide catheter. A Rota C wire (Boston Scientific) was advanced into the LAD and rotational atherectomy performed to the proximal and mid vessel, across the ostium of the RCA, using 1.5 and 1.75 mm Rotablator burrs (Boston Scientific). The Rota wire was then withdrawn and advanced into the RCA. An attempt was made to rotablate the calcified ostial stenosis with a 1.5 mm burr, but this could not be advanced across the bifurcation. The Rota wire was therefore withdrawn, and dual 0.0014 Balance wires (Guidant) were positioned in the LAD and RCA. Simultaneous kissing balloon predilatation was performed with a
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.03.012
Das, Meredith Intervention to an anomalous coronary
343 CASE REPORT
Heart, Lung and Circulation 2006;15:342–345
Figure 1. Courses of the left anterior descending (LAD), anomalous right coronary artery (RCA) and circumflex artery (LCX) seen in the shallow right anterior oblique cranial projection.
2.25 mm × 20 mm Sprinter balloon (Medtronic) in the LAD and a 2 mm × 20 mm Sprinter balloon in the RCA, both at 12 atm. Simultaneous kissing stenting was then performed using two 2.25 mm × 24 mm Taxus stents (Boston Scientific) from the proximal LAD into the mid LAD and RCA branches (Fig. 3). The stents were postdilated with kissing balloons: a 2.25 mm × 18 mm Powersail (Guidant) in the LAD at 18 atm and a 2 mm × 20 mm Ryujin (Terumo) in the RCA at 18 atm. A satisfactory angiographic result was achieved, with TIMI grade 3 flow in both branches (Fig. 4A and B). The patient remained stable during the procedure and recovered without complication. At two-month follow-up he reported resolution of the chest pain.
Discussion Coronary artery anomalies have been described in up to 1.5% of adults undergoing coronary angiography.1 A number of patterns have been identified and were classified by Lipton et al.2 Where a single coronary artery arises from the left coronary sinus, the right coronary artery may arise from the left anterior descending artery and pass anterior to the right ventricle as in this case, between the aorta and pulmonary trunk, or posterior to the aorta.3 These represent Lipton type L-IIA, B and P anomalies, respectively, and accounted for just 11 cases in a series of 126,595 coronary angiograms reported by Yanmanaka and Hobbs.1 In older patients such as this case, anomalous coronary arteries are less likely to be associated with other cardiac defects and can be subject to atherosclerosis in the same manner as normal coronaries.
Figure 2. (A) Frame prior to contrast injection demonstrating calcification at the bifurcation of left anterior descending and right coronaries in the shallow left anterior oblique caudal projection. (B) Bifurcation lesion of the in the shallow left anterior oblique caudal projection (LAD: left anterior descending artery; RCA: right coronary artery).
There have been several reports of coronary angioplasty and stenting to anomalous coronary arteries. Lawson et al. gave the first account of stenting to an anomalous LAD artery distal to its origin from the RCA.4 Hsu et al. reported a case with similar coronary anatomy to that of our patient.5 They performed angioplasty and stenting of a stenosis in a single coronary artery proximal to the
344
Das, Meredith Intervention to an anomalous coronary
Heart, Lung and Circulation 2006;15:342–345
CASE REPORT
Figure 3. Simultaneous kissing stenting of the bifurcation in the shallow right anterior oblique cranial projection.
origin of an anomalous RCA in a 61-year-old man presenting with an acute anterior and inferior myocardial infarction. In this case, the main obstacles to successful intervention were the burden of calcification at the bifurcation and the acute angle between the RCA and the LAD. We therefore performed rotational atherectomy at start of the procedure to debulk the bifurcation, allowing subsequent balloon angioplasty at moderate pressure and facilitating the passage of the stents. Rotational atherectomy of an artery or branch with an incident angle of more than 60◦ can be technically challenging with greater risk, and in practice we were unable to burr into the right coronary artery. Despite this, having debulked the LAD we were able to introduce and deploy kissing stents without difficulty. Simultaneous kissing stenting is a form of V stenting in which two stents are deployed into branches with more than 5 mm of proximal apposition in the main vessel, forming an artificial carina. It has been reported with an initial procedural success rate of 99% and 30-day target lesion revascularisation rate of 5% in a series of 100 patients.6 Kissing stenting is suitable for cases of this kind where the diameter of the proximal vessel is at least two thirds the sum of the diameters of the distal branches, to accommodate the proximal sections of both stents. We believe this to be the first reported case of angioplasty to a bifurcation lesion of the LAD and an anomalous RCA. The case illustrates several of the challenges presented by lesions in anomalous coronary arteries and the solutions achieved from the application of contemporary interventional techniques.
Figure 4. (A) Final left anterior oblique caudal view showing the stented bifurcation. (B) Shallow right anterior oblique cranial projection demonstrating successful bifurcational stenting.
References 1. Yanmanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Cathet Cardiovasc Diagn 1990;21:28–40. 2. 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. 3. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–63.
4. Lawton J, McGrath J, Jones JS, Dehmer GJ. Treatment of coronary artery disease in an anomalous coronary artery by placement of an intracoronary stent. Cathet Cardiovasc Diagn 1997;41:185–8. 5. Hsu LA, Chu PH, Ko YS, Ko YL, Chiang CW. Transluminal coronary angioplasty and stenting in a patient with single coronary
Das, Meredith Intervention to an anomalous coronary
345
artery and acute myocardial infarction. Changgeng Yi Xue Za Zhi 1997;20:299–303. 6. Sharma SK, Choudhury A, Lee J, Kim MC, Fisher E, Steinheimer AM, et al. Simultaneous kissing stents (SKS) technique for treating bifurcation lesions in medium-to-large size coronary arteries. Am J Cardiol 2004;94:913–7.
CASE REPORT
Heart, Lung and Circulation 2006;15:342–345
Case Report
Rotational Atherectomy and Simultaneous Kissing Stenting of a Bifurcation Stenosis of Left Anterior Descending and Anomalous Right Coronary Arteries Paul K. Das, MD ∗ and Ian T. Meredith, PhD Cardiovascular Research Centre, Monash Medical Centre, Melbourne, Australia
Intervention to anomalous coronaries can present specific challenges: non-standard guide catheters may be required to provide adequate access and support, the course of the arteries can be tortuous with sharp angulations, and they may subtend a critical area of myocardium. We present the first report of percutaneous coronary intervention to the bifurcation of an anomalous right coronary artery arising from the left anterior descending artery. This lesion contained a high burden of calcification, which required rotational atherectomy of the left anterior descending artery before kissing stenting of the bifurcation. (Heart, Lung and Circulation 2006;15:342–345) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Coronary angioplasty; Rotational atherectomy; Coronary vessel anomalies
Case Report
A
71-year-old man was referred for coronary angiography. He had insulin dependant type II diabetes, hypertension and hiatus hernia. He had experienced intermittent chest pain for several years, which had recently increased in frequency. Gastroscopy was normal. Coronary angiography was performed using a 6 French Judkins L4 catheter. This demonstrated a single coronary artery of large calibre arising from the left coronary cusp following the normal course of the left main stem and left anterior descending artery (LAD). The left circumflex (LCX) arose from the main stem in the normal way and was a large, dominant vessel. The right coronary artery (RCA) was a smaller vessel which arose from the proximal LAD opposite the first septal branch at approximately 70◦ (Fig. 1). It passed anteriorly across the epicardial surface of the right ventricular outflow tract before entering the right atrioventricular groove, giving rise to a left ventricular branch. There was calcification of the proximal LAD and a calcified tubular 70–80% stenosis at the bifurcation of the Received 14 December 2005; accepted 28 March 2006; available online 12 May 2006 ∗
Correspondence to: Cardiovascular Research Centre, Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168, Australia. Tel.: +61 3 9594 4547; fax: +61 3 9594 4307. E-mail address: [email protected] (P.K. Das).
anomalous RCA (Fig. 2A and B). The LAD was of smaller calibre beyond the bifurcation. The RCA itself had calcified ostial and proximal 80% stenosis (Fig. 1). The circumflex had only minor irregularities. An aortogram showed no evidence of a separate RCA origin. Left ventricular ejection fraction was normal. After discussion at a joint surgical case conference, we elected to perform angioplasty and stenting to both branches of the bifurcation. We commenced with rotational atherectomy to reduce the burden of calcium in the lesion and assist stent passage into the sharply angulated ostium of the RCA. The patient was given pre-loading doses of aspirin 300 mg, clopidogrel 600 mg and intravenous heparin 70 units/kg. A temporary pacing wire was placed in the right ventricle. The left main stem was engaged with a 7French Extra Back Up 4.0 guide catheter. A Rota C wire (Boston Scientific) was advanced into the LAD and rotational atherectomy performed to the proximal and mid vessel, across the ostium of the RCA, using 1.5 and 1.75 mm Rotablator burrs (Boston Scientific). The Rota wire was then withdrawn and advanced into the RCA. An attempt was made to rotablate the calcified ostial stenosis with a 1.5 mm burr, but this could not be advanced across the bifurcation. The Rota wire was therefore withdrawn, and dual 0.0014 Balance wires (Guidant) were positioned in the LAD and RCA. Simultaneous kissing balloon predilatation was performed with a
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.03.012
Das, Meredith Intervention to an anomalous coronary
343 CASE REPORT
Heart, Lung and Circulation 2006;15:342–345
Figure 1. Courses of the left anterior descending (LAD), anomalous right coronary artery (RCA) and circumflex artery (LCX) seen in the shallow right anterior oblique cranial projection.
2.25 mm × 20 mm Sprinter balloon (Medtronic) in the LAD and a 2 mm × 20 mm Sprinter balloon in the RCA, both at 12 atm. Simultaneous kissing stenting was then performed using two 2.25 mm × 24 mm Taxus stents (Boston Scientific) from the proximal LAD into the mid LAD and RCA branches (Fig. 3). The stents were postdilated with kissing balloons: a 2.25 mm × 18 mm Powersail (Guidant) in the LAD at 18 atm and a 2 mm × 20 mm Ryujin (Terumo) in the RCA at 18 atm. A satisfactory angiographic result was achieved, with TIMI grade 3 flow in both branches (Fig. 4A and B). The patient remained stable during the procedure and recovered without complication. At two-month follow-up he reported resolution of the chest pain.
Discussion Coronary artery anomalies have been described in up to 1.5% of adults undergoing coronary angiography.1 A number of patterns have been identified and were classified by Lipton et al.2 Where a single coronary artery arises from the left coronary sinus, the right coronary artery may arise from the left anterior descending artery and pass anterior to the right ventricle as in this case, between the aorta and pulmonary trunk, or posterior to the aorta.3 These represent Lipton type L-IIA, B and P anomalies, respectively, and accounted for just 11 cases in a series of 126,595 coronary angiograms reported by Yanmanaka and Hobbs.1 In older patients such as this case, anomalous coronary arteries are less likely to be associated with other cardiac defects and can be subject to atherosclerosis in the same manner as normal coronaries.
Figure 2. (A) Frame prior to contrast injection demonstrating calcification at the bifurcation of left anterior descending and right coronaries in the shallow left anterior oblique caudal projection. (B) Bifurcation lesion of the in the shallow left anterior oblique caudal projection (LAD: left anterior descending artery; RCA: right coronary artery).
There have been several reports of coronary angioplasty and stenting to anomalous coronary arteries. Lawson et al. gave the first account of stenting to an anomalous LAD artery distal to its origin from the RCA.4 Hsu et al. reported a case with similar coronary anatomy to that of our patient.5 They performed angioplasty and stenting of a stenosis in a single coronary artery proximal to the
344
Das, Meredith Intervention to an anomalous coronary
Heart, Lung and Circulation 2006;15:342–345
CASE REPORT
Figure 3. Simultaneous kissing stenting of the bifurcation in the shallow right anterior oblique cranial projection.
origin of an anomalous RCA in a 61-year-old man presenting with an acute anterior and inferior myocardial infarction. In this case, the main obstacles to successful intervention were the burden of calcification at the bifurcation and the acute angle between the RCA and the LAD. We therefore performed rotational atherectomy at start of the procedure to debulk the bifurcation, allowing subsequent balloon angioplasty at moderate pressure and facilitating the passage of the stents. Rotational atherectomy of an artery or branch with an incident angle of more than 60◦ can be technically challenging with greater risk, and in practice we were unable to burr into the right coronary artery. Despite this, having debulked the LAD we were able to introduce and deploy kissing stents without difficulty. Simultaneous kissing stenting is a form of V stenting in which two stents are deployed into branches with more than 5 mm of proximal apposition in the main vessel, forming an artificial carina. It has been reported with an initial procedural success rate of 99% and 30-day target lesion revascularisation rate of 5% in a series of 100 patients.6 Kissing stenting is suitable for cases of this kind where the diameter of the proximal vessel is at least two thirds the sum of the diameters of the distal branches, to accommodate the proximal sections of both stents. We believe this to be the first reported case of angioplasty to a bifurcation lesion of the LAD and an anomalous RCA. The case illustrates several of the challenges presented by lesions in anomalous coronary arteries and the solutions achieved from the application of contemporary interventional techniques.
Figure 4. (A) Final left anterior oblique caudal view showing the stented bifurcation. (B) Shallow right anterior oblique cranial projection demonstrating successful bifurcational stenting.
References 1. Yanmanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Cathet Cardiovasc Diagn 1990;21:28–40. 2. 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. 3. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–63.
4. Lawton J, McGrath J, Jones JS, Dehmer GJ. Treatment of coronary artery disease in an anomalous coronary artery by placement of an intracoronary stent. Cathet Cardiovasc Diagn 1997;41:185–8. 5. Hsu LA, Chu PH, Ko YS, Ko YL, Chiang CW. Transluminal coronary angioplasty and stenting in a patient with single coronary
Das, Meredith Intervention to an anomalous coronary
345
artery and acute myocardial infarction. Changgeng Yi Xue Za Zhi 1997;20:299–303. 6. Sharma SK, Choudhury A, Lee J, Kim MC, Fisher E, Steinheimer AM, et al. Simultaneous kissing stents (SKS) technique for treating bifurcation lesions in medium-to-large size coronary arteries. Am J Cardiol 2004;94:913–7.
CASE REPORT
Heart, Lung and Circulation 2006;15:342–345