Percutaneous coronary intervention with anomalous origin of right coronary artery: case reports and literature review
A 68-year-old male presented to the hospital with complaints of exertional substernal chest pain for three months duration. His symptoms were worsened on laboring for five days. He has a history of tobacco abuse and hypertension, but denied a prior medical history of diabetes. On admission, he was mildly hypertensive (150/70 mmHg) with a regular rhythm of 70 beats per minute. Cardiac auscultation was unremarkable. The electrocardiogram at admission revealed mild depression of the ST segment in leads II, III, aVF and marked by an exercising test. His echocardiography showed no obvious abnormal motion of ventricular wall. The report of lab analyses, such as troponin and the remaining cardiac enzymes, blood lipoids and FBG were negative. According to the results of the above examinations, he was diagnosed as having an unstable angina pectoris. The patient received conventional medicine preconditioning before the invasive angiography such as dual antiplatelet therapy (aspirin 100 mg/d and clopidogrel 300 mg once and thereafter at a dose of 75 mg/d); and the remaining therapy which included statin, nitrate and perindopril. A selective coronary angiography (CAG) with access through the right femoral artery was performed. The image of CAG revealed insignificant stenoses of the left coronary, but the wandering position of the RCA ostium. Selective cannulation of the RCA could not be achieved with either a Judkins right 3.5, or a 4.0 cm curve diagnostic catheter. Nonselective imaging of the ascending aorta revealed an aberrant origin of the RCA from antetheca of the aortic wall. Therefore, an Amplatzer left 0.75 cm curve catheter was selectively manipulated into the aberrant RCA and revealed an 85% lesion in the proximal RCA (). Subsequently, PCI was performed with a 6 Fr Amplatzer left 0.75 cm guiding catheter (Medtronic, USA), which provided terrible coaxialilty and support as a result of the anomalous anatomic originate of RCA ostium. We stepped a 0.014 inch BMW guide wire (Guidant, USA) “gone with the flow” and manipulated it to the distal-RCA predilated with a 2.5–15 mm Ryujin balloon catheter (TERUMO, Japan). Stent placement was accomplished with a 3.0–13 mm Partner drug eluting stent (Lepu, China) and delivered at 20 atm. The final result indicated insignificant remaining stenosis (). The patient was discharged on the second day of the procedures with continued dual antiplatelet therapy which included the daily regimen of aspirin 100 mg and clopidogrel 75 mg lasting for one year. There was also no dissection, thrombus, perioperative myocardial infarction, heart failure, stroke or death during the stent implanting procedure and he did not suffer from MACE during the follow-up period.