Percutaneous coronary intervention with anomalous origin of right coronary artery: case reports and literature review
A 75 year-old male presented to the hospital with complaints of spontaneous substernal chest pain for three weeks. He has a prior history of tobacco abuse and intractable hypertension but denied diabetes. Upon admission, he was strikingly hypertensive (190/100 mmHg) with a regular heart rate of 89 beats per minute. He showed clear consciousness and other physical examinations documented normal findings. The electrocardiogram at admission revealed striking depression of the ST segment in leads II, III, aVF and mild depression of ST segment in V2-V5. His echocardiography showed no obvious abnormal motion of ventricular wall. The lab analyses, such as troponin and the remaining cardiac enzymes, lipoid profiles, fast blood glucose (FBG) and oral glucose tolerance test (OGTT), 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 earlier invasive assessment, 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, nicardipine, metoprolol succinate and perindopril, an angiotensin converting enzyme inhibitor (ACEI). He was referred to the catheterization laboratory for coronary angiography (CAG) through the access of the right femoral artery. The selective cannulation of the left coronary artery simultaneously revealed significant stenoses of the left anterior descending coronary (LAD) and an aberrant origin of the RCA from the left coronary sinus (LCS) near the left main trunk. We manipulated the Judkins left 4.0 cm curve catheter to engage the aberrant RCA selectively without difficulty and revealed a 99% lesion in the mid-portion of the right coronary artery (). Subsequently, PCI was performed painstakingly with use of a 6 French (Fr) Judkins left 4.0 cm guiding catheter (Cordis, USA), which failed to provided adequate support and was badly coaxialilty due to the anomalous anatomic originate of RCA. We advanced a 0.014 inch BMW guide wire (Guidant, USA) “gone with the flow” and manipulated it to the distal-RCA pre-dilated with a 2.0–20 mm Ryujin balloon catheter (TERUMO, Japan). During the process of balloon pre-dilated, the operator utilized the anchoring force of the expansion balloon to lead the guide catheter to the appropriate place, but failed to complete the process of delivering the stent to the lesions. Therefore, we advanced two WHISPER (Cordis, USA) guide wires into the distal-LAD aimed to augmented the anchoring force. Finally, stent installment was accomplished with a 3.0–13 mm Partner coronary stent (Lepu, China) delivered at 18 atm. The result was a remaining stenosis of less than 10% (). The operational time of this case was 55 min and the dosage of contrast agent was 85 mL. The patient underwent an uneventful hospital course and was discharged the following day after the successful PCI for his LAD lesions. There was also no dissection, thrombus, perioperative myocardial infarction, heart failure, stroke or death during the PCI procedure. The subject remained free from MACE during an outpatient follow-up period of 18 months.