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Successful percutaneous intervention of proximal left anterior descending artery in a case of single coronary artery trunk
Journal of Cardiology Cases 10 (2014) 205–207
Contents lists available at ScienceDirect
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
Successful percutaneous intervention of proximal left anterior descending artery in a case of single coronary artery trunk Jalal Zamani (MD)a, Abdolali Zolghadrasli (MD)b,* a b
Shiraz University of Medical Sciences, School of Medicine, Department of Cardiology, Shiraz, Iran Shiraz University of Medical Sciences, Shiraz Cardiovascular Research Center, Shiraz, Iran
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 October 2013 Received in revised form 11 July 2014 Accepted 16 July 2014
Congenital coronary anomalies are mostly asymptomatic, detected accidentally during invasive or noninvasive imaging. One of the least encountered of such anomalies is single coronary ostium. Considering the fact that the whole myocardium is perfused by a single coronary vessel, performing percutaneous coronary stenting is a challenge for interventional cardiologists with some authors even considering it as a contraindication. Here we present a rare case of single coronary artery as a result of terminal extension of right coronary artery from left circumflex artery, for whom successful balloon angioplasty and stenting of left anterior descending artery after myocardial infarction was done. ß 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Keywords: Percutaneous coronary intervention Single coronary artery Coronary artery anomaly Anomalous right coronary artery origin
Introduction Congenital coronary artery anomalies are mostly accidentally detected during invasive or non-invasive imaging studies of the coronary system and reported with a frequency as low as 0.6% to as high as 5.6% [1,2]. One of the least encountered coronary anomalies is single coronary ostium reported to occur in about 0.05% of the population [1]. Here we present a case of single coronary artery (SCA) as a result of terminal extension of right coronary artery (RCA) from left circumflex artery (LCx), for whom successful percutaneous coronary intervention (PCI) in the form of balloon angioplasty and stenting of left anterior descending artery (LAD) after myocardial infarction (MI) was done.
Case report A 55-year-old male was admitted to the emergency department of a local hospital with severe retrosternal anginal pain which had started since 3 h before admission. He was a heavy cigarette
* Corresponding author at: Shiraz Cardiovascular Research Center, Shahid Faghihi Hospital, Zand Avenue, PO Box 7134844119, Shariz, Iran. Tel.: +98 711 2342248; fax: +98 711 2342248. E-mail address: [email protected] (A. Zolghadrasli).
smoker without previous history of diabetes, hypertension, or hyperlipidemia. His family history was unremarkable. His physical examination was reported to be normal. His electrocardiogram (ECG) showed ST segment elevation from V1 through V6 and he received intravenous thrombolytic therapy with diagnosis of anterior wall acute ST-elevation MI with acceptable clinical and electrocardiographic response. His serial ECGs revealed normal evolution of an anterior MI with loss of R wave amplitude in precordial leads (Fig. 1). His serum troponin was highly positive. His echocardiogram showed mild left ventricular (LV) dilation, hypokinesia of the anterior and apical region, and ejection fraction of 40%. His coronary care unit stay was uneventful and he was discharged home after 5 days. He was referred 1 month later to our outpatient department for further evaluation and because of continued impaired LV systolic function he was scheduled for coronary angiography. Coronary angiography via right femoral approach revealed normal left main coronary artery and LCx, but significant proximal LAD lesion was detected. What was unexpected in this study was gradual filling of the RCA from distal of LCx in its natural course up to right coronary ostium (Fig. 2). An aortography confirmed absence of right coronary ostium and the diagnosis of SCA from left cusp. It was then decided to perform ad hoc angioplasty and stenting of the LAD lesion. For this purpose a 6F Judkins left guiding catheter with good flexibility and support was used (Launcher, Medtronic Vascular, Minneapolis, MN, USA).
http://dx.doi.org/10.1016/j.jccase.2014.07.011 1878-5409/ß 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
206
Fig. 1.
J. Zamani, A. Zolghadrasli / Journal of Cardiology Cases 10 (2014) 205–207
12-Lead electrocardiogram taken after 1 month which shows ST-T changes in precordial leads indicative of aged anterior myocardial infarction.
A torquable 0.014 in. guide wire (Hi-Torque Balanced Middleweight Universal, Abbott Vascular, Abbott Park, IL, USA) was carefully crossed across the lesion. Then a 3 mm 28 mm paclitaxel-eluting stent (Taxcor, Eurocor, Bonn, Germany) was inserted inside the lesion at 12 atmosphere pressure which was
Fig. 2.
Right anterior oblique and caudal view showing proximal significant lesion of LAD (white arrow) and RCA arising as terminal extension of LCx. LAD, left anterior descending artery; RCA, right coronary artery; LCx, left circumflex artery.
then dilated with a 2.75 mm 13 mm non-compliant balloon at 16 atmosphere (Trek, Abbot Vascular). Different angiographic projections revealed excellent result with no complications (Fig. 3). The patient was discharged the following day and is asymptomatic after 1 year of follow-up.
Fig. 3.
Lateral projection of the patient after successful stenting of the LAD lesion. White arrow pointing to stent. LAD, left anterior descending artery; RCA, right coronary artery; LCx, left circumflex artery.
J. Zamani, A. Zolghadrasli / Journal of Cardiology Cases 10 (2014) 205–207
Discussion Coronary artery anomaly is reported in 0.6–1.3% of patients undergoing conventional coronary angiography, 0.7–18.4% of patients undergoing computed tomography angiography (CTA), and in 0.3% of surgery and autopsy series [1]. Anomalous origin of RCA is a rare congenital anomaly which was first described by White and Edwards in 1948 [3]. One of the presentations of anomalous RCA is in the form of SCA. SCA is one of the rare coronary anomalies occurring in 0.024–0.066% of patients studied [1]. In most of the patients RCA arises from LAD and its origin from LCx is less encountered [4]. According to the anatomical classification of SCA, the anomaly reported in this article is classified as L-1 which has been reported by few authors [4]. Although SCA is overall considered a benign anomaly, some authors have reported that 15% of patients with SCA had myocardial ischemia due to the direct consequence of the coronary anomaly [5]. There is some controversy regarding the role of congenital anomalies and atherosclerosis. Some reports suggest that anomalous arteries are more prone to atherosclerosis, but others have not found any relation and state that the finding of atherosclerosis in a patient with coronary anomaly is just a coincidence [1,4,6]. Whatever the relationship, this will certainly have clinical implications regarding management of atherosclerotic lesions. One of the challenges is the role of PCI in such patients. Regarding the fact that the whole myocardium is perfused by a SCA, some authors consider PCI a relative contraindication in this setting because of ostial obstruction by large guiding catheters, the catastrophic outcome in the event of coronary dissection, and also considering the risk of sudden death posed by the possibility of re-stenosis in such patients [7,8]. On the other hand, with increased expertise of interventional cardiologists and evolution of new devices in this field, the decision to perform angioplasty, versus coronary artery bypass graft, is gaining momentum [6,8–10]. PCI in SCA lesions will surely pose challenges but all these challenges can be overcome with the use of guiding catheters with good flexibility, support and visualization, torquable guide wires, and finally meticulous use of stents and balloons with proper pressures to ensure adequate lesion expansion without compromise of the overall procedure. The safety of the procedure can also be improved with the utilization of experienced staff and back-up surgical team. Another point to mention is the role of non-invasive imaging in the management of these patients. While conventional coronary angiography is still the standard procedure, some authors have advocated routine use of modalities like pressure-wire and intravascular ultrasonography to determine the functional and structural importance of the lesion [2]. CTA is also a new and interesting modality; besides being noninvasive, CTA allows visualization of adjacent structures and better comprehension of the origin and course of the coronary arteries [10]. Considering the
207
fact that SCA is sometimes associated with other congenital abnormalities of the heart including transposition of the great vessels, bicuspid aortic valve and coronary arteriovenous fistula which may affect the decision-making process, the routine use of CTA before might be considered in such patients [7]. In our case we detected the coronary anomaly accidentally during a routine angiographic study and because of clear visualization of the anomalous artery and lack of any associated congenital anomalies in previous echocardiographic studies, we decided against CTA and opted to continue with ad hoc angioplasty. Hereby we have presented another successful PCI of an atherosclerotic lesion in a SCA without any complications. This report, beside some few other successful ones, will surely encourage interventionists to address such lesions more frequently. It seems that PCI can be performed safely in such patients, although further data and evaluation is certainly needed and longterm follow-up of these patients will provide further insight. Funding None. Conflict of interest No conflict of interests to declare. References [1] Erol C, Seker M. Coronary artery anomalies: the prevalence of origination, course, and termination anomalies of coronary arteries detected by 64detector computed tomography coronary angiography. J Comput Assist Tomogr 2011;35:618–24. [2] Angelini P. Coronary artery anomalies – current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29:271–8. [3] Shojaie M, Eshraghian A. Single left coronary artery with origin of right coronary artery from left circumflex: a case report. Cases J 2008;1:355. [4] Tanriverdi H, Seleci D, Kuru O, Semiz E. Right coronary artery arising as a terminal extension of the circumflex artery (a rare coronary artery anomaly). Can J Cardiol 2007;23:737–8. [5] Chou LP, Kao C, Lee MC, Lin SL. Right coronary artery originating from distal left circumflex artery in a patient with an unusual type of isolated single coronary artery. Jpn Heart J 2004;45:337–42. [6] Rudan D, Todorovic N, Starcevic B, Raguz M, Bergovec M. Percutaneous coronary intervention of an anomalous right coronary artery originating from the left coronary artery. Wien Klin Wochenschr 2010;122:508–10. [7] Celik T, Iyisoy A, Yu¨ksel C, Is¸ik E. Anomalous right coronary artery arising from the distal left circumflex coronary artery. Anadolu Kardiyol Derg 2008;8: 459–60. [8] Kafkas N, Triantafyllou K, Babalis D. An isolated single L-I type coronary artery with severe LAD lesions treated by transradial PCI. J Invasive Cardiol 2011;23:E216–8. [9] Chung SK, Lee SJ, Park SH. An extremely rare variety of anomalous coronary artery: right coronary artery originating from the distal left circumflex artery. Korean Circ J 2010;40:465–7. [10] Devidutta S, Sharma G, Jagia P. Coronary stenting in a patient with single coronary artery and double-vessel disease! J Invasive Cardiol 2013;25: E147–50.
Contents lists available at ScienceDirect
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
Successful percutaneous intervention of proximal left anterior descending artery in a case of single coronary artery trunk Jalal Zamani (MD)a, Abdolali Zolghadrasli (MD)b,* a b
Shiraz University of Medical Sciences, School of Medicine, Department of Cardiology, Shiraz, Iran Shiraz University of Medical Sciences, Shiraz Cardiovascular Research Center, Shiraz, Iran
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 October 2013 Received in revised form 11 July 2014 Accepted 16 July 2014
Congenital coronary anomalies are mostly asymptomatic, detected accidentally during invasive or noninvasive imaging. One of the least encountered of such anomalies is single coronary ostium. Considering the fact that the whole myocardium is perfused by a single coronary vessel, performing percutaneous coronary stenting is a challenge for interventional cardiologists with some authors even considering it as a contraindication. Here we present a rare case of single coronary artery as a result of terminal extension of right coronary artery from left circumflex artery, for whom successful balloon angioplasty and stenting of left anterior descending artery after myocardial infarction was done.
Keywords: Percutaneous coronary intervention Single coronary artery Coronary artery anomaly Anomalous right coronary artery origin
Introduction Congenital coronary artery anomalies are mostly accidentally detected during invasive or non-invasive imaging studies of the coronary system and reported with a frequency as low as 0.6% to as high as 5.6% [1,2]. One of the least encountered coronary anomalies is single coronary ostium reported to occur in about 0.05% of the population [1]. Here we present a case of single coronary artery (SCA) as a result of terminal extension of right coronary artery (RCA) from left circumflex artery (LCx), for whom successful percutaneous coronary intervention (PCI) in the form of balloon angioplasty and stenting of left anterior descending artery (LAD) after myocardial infarction (MI) was done.
Case report A 55-year-old male was admitted to the emergency department of a local hospital with severe retrosternal anginal pain which had started since 3 h before admission. He was a heavy cigarette
* Corresponding author at: Shiraz Cardiovascular Research Center, Shahid Faghihi Hospital, Zand Avenue, PO Box 7134844119, Shariz, Iran. Tel.: +98 711 2342248; fax: +98 711 2342248. E-mail address: [email protected] (A. Zolghadrasli).
smoker without previous history of diabetes, hypertension, or hyperlipidemia. His family history was unremarkable. His physical examination was reported to be normal. His electrocardiogram (ECG) showed ST segment elevation from V1 through V6 and he received intravenous thrombolytic therapy with diagnosis of anterior wall acute ST-elevation MI with acceptable clinical and electrocardiographic response. His serial ECGs revealed normal evolution of an anterior MI with loss of R wave amplitude in precordial leads (Fig. 1). His serum troponin was highly positive. His echocardiogram showed mild left ventricular (LV) dilation, hypokinesia of the anterior and apical region, and ejection fraction of 40%. His coronary care unit stay was uneventful and he was discharged home after 5 days. He was referred 1 month later to our outpatient department for further evaluation and because of continued impaired LV systolic function he was scheduled for coronary angiography. Coronary angiography via right femoral approach revealed normal left main coronary artery and LCx, but significant proximal LAD lesion was detected. What was unexpected in this study was gradual filling of the RCA from distal of LCx in its natural course up to right coronary ostium (Fig. 2). An aortography confirmed absence of right coronary ostium and the diagnosis of SCA from left cusp. It was then decided to perform ad hoc angioplasty and stenting of the LAD lesion. For this purpose a 6F Judkins left guiding catheter with good flexibility and support was used (Launcher, Medtronic Vascular, Minneapolis, MN, USA).
http://dx.doi.org/10.1016/j.jccase.2014.07.011 1878-5409/ß 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
206
Fig. 1.
J. Zamani, A. Zolghadrasli / Journal of Cardiology Cases 10 (2014) 205–207
12-Lead electrocardiogram taken after 1 month which shows ST-T changes in precordial leads indicative of aged anterior myocardial infarction.
A torquable 0.014 in. guide wire (Hi-Torque Balanced Middleweight Universal, Abbott Vascular, Abbott Park, IL, USA) was carefully crossed across the lesion. Then a 3 mm 28 mm paclitaxel-eluting stent (Taxcor, Eurocor, Bonn, Germany) was inserted inside the lesion at 12 atmosphere pressure which was
Fig. 2.
Right anterior oblique and caudal view showing proximal significant lesion of LAD (white arrow) and RCA arising as terminal extension of LCx. LAD, left anterior descending artery; RCA, right coronary artery; LCx, left circumflex artery.
then dilated with a 2.75 mm 13 mm non-compliant balloon at 16 atmosphere (Trek, Abbot Vascular). Different angiographic projections revealed excellent result with no complications (Fig. 3). The patient was discharged the following day and is asymptomatic after 1 year of follow-up.
Fig. 3.
Lateral projection of the patient after successful stenting of the LAD lesion. White arrow pointing to stent. LAD, left anterior descending artery; RCA, right coronary artery; LCx, left circumflex artery.
J. Zamani, A. Zolghadrasli / Journal of Cardiology Cases 10 (2014) 205–207
Discussion Coronary artery anomaly is reported in 0.6–1.3% of patients undergoing conventional coronary angiography, 0.7–18.4% of patients undergoing computed tomography angiography (CTA), and in 0.3% of surgery and autopsy series [1]. Anomalous origin of RCA is a rare congenital anomaly which was first described by White and Edwards in 1948 [3]. One of the presentations of anomalous RCA is in the form of SCA. SCA is one of the rare coronary anomalies occurring in 0.024–0.066% of patients studied [1]. In most of the patients RCA arises from LAD and its origin from LCx is less encountered [4]. According to the anatomical classification of SCA, the anomaly reported in this article is classified as L-1 which has been reported by few authors [4]. Although SCA is overall considered a benign anomaly, some authors have reported that 15% of patients with SCA had myocardial ischemia due to the direct consequence of the coronary anomaly [5]. There is some controversy regarding the role of congenital anomalies and atherosclerosis. Some reports suggest that anomalous arteries are more prone to atherosclerosis, but others have not found any relation and state that the finding of atherosclerosis in a patient with coronary anomaly is just a coincidence [1,4,6]. Whatever the relationship, this will certainly have clinical implications regarding management of atherosclerotic lesions. One of the challenges is the role of PCI in such patients. Regarding the fact that the whole myocardium is perfused by a SCA, some authors consider PCI a relative contraindication in this setting because of ostial obstruction by large guiding catheters, the catastrophic outcome in the event of coronary dissection, and also considering the risk of sudden death posed by the possibility of re-stenosis in such patients [7,8]. On the other hand, with increased expertise of interventional cardiologists and evolution of new devices in this field, the decision to perform angioplasty, versus coronary artery bypass graft, is gaining momentum [6,8–10]. PCI in SCA lesions will surely pose challenges but all these challenges can be overcome with the use of guiding catheters with good flexibility, support and visualization, torquable guide wires, and finally meticulous use of stents and balloons with proper pressures to ensure adequate lesion expansion without compromise of the overall procedure. The safety of the procedure can also be improved with the utilization of experienced staff and back-up surgical team. Another point to mention is the role of non-invasive imaging in the management of these patients. While conventional coronary angiography is still the standard procedure, some authors have advocated routine use of modalities like pressure-wire and intravascular ultrasonography to determine the functional and structural importance of the lesion [2]. CTA is also a new and interesting modality; besides being noninvasive, CTA allows visualization of adjacent structures and better comprehension of the origin and course of the coronary arteries [10]. Considering the
207
fact that SCA is sometimes associated with other congenital abnormalities of the heart including transposition of the great vessels, bicuspid aortic valve and coronary arteriovenous fistula which may affect the decision-making process, the routine use of CTA before might be considered in such patients [7]. In our case we detected the coronary anomaly accidentally during a routine angiographic study and because of clear visualization of the anomalous artery and lack of any associated congenital anomalies in previous echocardiographic studies, we decided against CTA and opted to continue with ad hoc angioplasty. Hereby we have presented another successful PCI of an atherosclerotic lesion in a SCA without any complications. This report, beside some few other successful ones, will surely encourage interventionists to address such lesions more frequently. It seems that PCI can be performed safely in such patients, although further data and evaluation is certainly needed and longterm follow-up of these patients will provide further insight. Funding None. Conflict of interest No conflict of interests to declare. References [1] Erol C, Seker M. Coronary artery anomalies: the prevalence of origination, course, and termination anomalies of coronary arteries detected by 64detector computed tomography coronary angiography. J Comput Assist Tomogr 2011;35:618–24. [2] Angelini P. Coronary artery anomalies – current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29:271–8. [3] Shojaie M, Eshraghian A. Single left coronary artery with origin of right coronary artery from left circumflex: a case report. Cases J 2008;1:355. [4] Tanriverdi H, Seleci D, Kuru O, Semiz E. Right coronary artery arising as a terminal extension of the circumflex artery (a rare coronary artery anomaly). Can J Cardiol 2007;23:737–8. [5] Chou LP, Kao C, Lee MC, Lin SL. Right coronary artery originating from distal left circumflex artery in a patient with an unusual type of isolated single coronary artery. Jpn Heart J 2004;45:337–42. [6] Rudan D, Todorovic N, Starcevic B, Raguz M, Bergovec M. Percutaneous coronary intervention of an anomalous right coronary artery originating from the left coronary artery. Wien Klin Wochenschr 2010;122:508–10. [7] Celik T, Iyisoy A, Yu¨ksel C, Is¸ik E. Anomalous right coronary artery arising from the distal left circumflex coronary artery. Anadolu Kardiyol Derg 2008;8: 459–60. [8] Kafkas N, Triantafyllou K, Babalis D. An isolated single L-I type coronary artery with severe LAD lesions treated by transradial PCI. J Invasive Cardiol 2011;23:E216–8. [9] Chung SK, Lee SJ, Park SH. An extremely rare variety of anomalous coronary artery: right coronary artery originating from the distal left circumflex artery. Korean Circ J 2010;40:465–7. [10] Devidutta S, Sharma G, Jagia P. Coronary stenting in a patient with single coronary artery and double-vessel disease! J Invasive Cardiol 2013;25: E147–50.