Primary PCI in anomalous coronary: Wire first approach

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Acute myocardial infarction in an anomalous coronary artery is an uncommon occurrence. Elective (PCI) percutaneous coronary intervention in anomalous coronary in stable CAD is challenging. We report a case of Primary PCI in an unstable patient (recurrent VT) with anomalous coronary. Proximal portion of the occluded artery was delineated using non-selective injection of dye with inverted left judkins directed towards the ostium. The coronary guide wire was initially passed into the proximal lumen without guiding support by skilled manipulation over which the left judkins was engaged. The catheter was inverted when it engaged the anomalous ostium and the procedure was completed successfully.

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Primary PCI in anomalous coronary: Wire first approach

  1. 1. Primary PCI in anomalous coronary: Wire first approach
  2. 2. Case Report Primary PCI in anomalous coronary: Wire first approach Abhijit Kulkarni a, *, B. Ramesh b a Sr. Consultant, Department of Cardiology, Apollo Hospitals, Bangalore, India b Senior Consultant Cardiologist, Apollo Hospital, BG Road, Bangalore, India a r t i c l e i n f o Article history: Received 5 October 2013 Accepted 2 May 2014 Available online xxx Keywords: Percutaneous coronary intervention Acute coronary syndrome Cardiac catheterization Ostium a b s t r a c t Acute myocardial infarction in an anomalous coronary artery is an uncommon occurrence. Elective (PCI) percutaneous coronary intervention in anomalous coronary in stable CAD is challenging. We report a case of Primary PCI in an unstable patient (recurrent VT) with anomalous coronary. Proximal portion of the occluded artery was delineated using non- selective injection of dye with inverted left judkins directed towards the ostium. The coronary guide wire was initially passed into the proximal lumen without guiding support by skilled manipulation over which the left judkins was engaged. The catheter was inverted when it engaged the anomalous ostium and the procedure was completed successfully. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Case presentation A 26-year-old smoker with no co morbidities was admitted to our hospital with history of retrosternal chest pain with sweating since 3 h. Electrocardiogram showed ST elevations in inferior leads. He was administered heparin, nitrates and antiplatelets and was taken up for cardiac catheterization. The left anterior descending and left circumflex were normal (Fig. 1). Right coronary artery was seen filling through collaterals very faintly from the left side confirming the ECG findings. Right coronary ostium could not be engaged with Judkins Right catheter, No Torque Right or amplatz catheters (Figs. 2 and 3). Patient at this time became unstable with VT and was electrically cardioverted multiple times before stabilizing. Aortogram with pigtail performed at this stage showed faint opacification of an occluded anomalous right coronary artery arising near left coronary ostium in the late phase (Fig. 4). A left Judkins was chosen to attempt to engage the ostium, which was near the left ostium. The ostium and the proximal portion which was occluded were clearly delineated by the angiogram with inverted left judkins (Fig. 5). However, we could not cannulate the ostium and the patient had ongoing pain with two episodes of VT, which were cardioverted. This time BMW floppy wire was passed into the occluded artery by skilled manipulation while the catheter was still in the root (without guiding catheter support) (Fig. 6) and then over the wire the guiding catheter was engaged. Export thrombus aspiration catheter was used to aspirate the thrombus. 2.0 Â 8 mm TREK balloon (Fig. 7) was used and after predilation distal artery was visualized (Fig. 8). The thrombotic lesion was covered with 3 Â 24 mm PROMUS ELEMENT stent and TIMI III flow was achieved (Fig. 9). The patient stabilized electrically * Tel.: þ91 9008022866 (mobile). E-mail address: abhijitvilaskulkarni@yahoo.com (A. Kulkarni). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e4 Please cite this article in press as: Kulkarni A, Ramesh B, Primary PCI in anomalous coronary: Wire first approach, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.005 http://dx.doi.org/10.1016/j.apme.2014.05.005 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. and was discharged uneventfully. Asymptomatic at one year follow up. 2. Discussion The occurrence of acute coronary syndrome in an anomalous coronary requiring primary PCI is uncommon even in a high volume interventional centre. A recent prospective angio- graphic study reported the incidence of anomalous coronary from opposite sinus as 1.07%, which included a 0.92% rate of ectopic RCA originating from the left sinus and a 0.15% rate of ectopic LCA arising from the right sinus.1 An anomalous RCA might originate from the anterior aspect of the ascending aorta usually above the sinotubular line (high anterior take-off), from the left sinus of valsalva with a separate ostium from the left main coronary artery, from the left main coronary artery (as a single coronary ar- tery), or from the pulmonary trunk.2 Whether the anomalous origin by itself predisposes the patient to accelerated athero- sclerosis is a matter of debate. Hutchins et al3 suggested that Fig. 1 e Normal left coronary circulation. Fig. 2 e Unable to engage the right coronary with JR. Fig. 3 e Unable to engage the right coronary with NTR. Fig. 4 e Aortic root angiogram with pigtail. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e42 Please cite this article in press as: Kulkarni A, Ramesh B, Primary PCI in anomalous coronary: Wire first approach, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.005
  4. 4. the unusual angle of take-off and the more tortuous course of the proximal portion of the anomalous coronary artery can accelerate the rate of atherosclerosis. Liu et al4 suggested that the junction point of the bound portion and the free portion of an anomalous artery as it wraps around the aorta is an area that is susceptible to lipid accumulation. Technical aspect of the procedure can be challenging especially in an unstable patient as in our case. It is important to identify the culprit artery based on integration of ECG, Echo and angiogram reports so that search for the anomalous ar- tery is hastened. It is suggested to do an aortogram early and then choose catheters depending on position of anomalous ostium. The catheters suggested in case of anomalous right ostium are amplatz,5e7 voda6,7 or an undersized left judkins.8 Instead of “trial and error” for selection of catheter it is a useful strategy to manipulate the wire inside the root with guiding catheter directed towards the ostium so that wire enters the culprit artery especially in the setting of primary PCI. The guiding catheter can be engaged over the coronary guide wire for the subsequent procedure. This saves time and Fig. 5 e Occluded RCA delineated with JL catheter. Fig. 6 e Skilled manipulation resulting in wire in the RCA without guiding catheter support. Fig. 7 e 2 3 8 mm TREK balloon dilatation. Fig. 8 e Result of post balloon dilatation. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e4 3 Please cite this article in press as: Kulkarni A, Ramesh B, Primary PCI in anomalous coronary: Wire first approach, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.005
  5. 5. can affect the outcome of the therapeutic procedure. To our knowledge this technique of wiring the culprit artery without engaging the ostium is not reported earlier. 3. Conclusion The possibility of an anomalous coronary being the culprit artery should be considered when selective cannulation is not possible. Aortogram should be performed early to visualize the artery. Information from electrocardiography and echo- cardiogram is crucial and should be integrated to identify the culprit artery and to look for the anomalous course. Long runs during angiography to identify collaterals cannot be over- emphasized. Skilled manipulation of the coronary guide wire in the root to pass the wire into culprit artery and subsequent engagement by guiding might save time compared with trial and error method for selection of guiding catheter especially in ACS situations. CT coronary angiogram is not a useful method in ACS of anomalous coronary artery as it doesn’t have a therapeutic role. Conflicts of interest The author has none to declare. r e f e r e n c e s 1. Angelini P. Coronary artery anomaliesecurrent clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J. 2002; 29:271e278. 2. Lee Jung-Jin, Kim Dae-Hyeok, Byun Sung-Su. A case of acute myocardial infarction with the anomalous origin of the right coronary artery from the ascending aorta above the left sinus of valsalva and left coronary artery from the posterior sinus of valsalva. Yonsei Med J. 2009;50(1). 3. Hutchins GM, Miner MM, Boitnott JK. Vessel caliber and branch-angle of human coronary artery branch-points. Circ Res. 1976;38:572e576. 4. Liu LB, Richardson T, Taylor CB. Atherosclerotic occlusions in anomalous left circumflex coronary arteries. A report of 2 unusual cases and a review of pertinent literature. Paroi Arterielle. 1975;3:55e59. 5. Charney R, Spindola-Franco H, Grose R. Coronary angioplasty of anomalous right coronary arteries. Cathet Cardiovasc Diagn. 1993;29:233e235. 6. Yip H, Chen MC, Wu CJ. Primary angioplasty in acute inferior myocardial infarction with anomalous-origin right coronary arteries as infarct-related arteries: Focus on anatomic and clinical features, outcomes, selection of guiding catheters and management. J Invasive Cardiol. 2001;13:290e297. 7. Praharaj TK, Ray G. Percutaneous transluminal coronary angioplasty with stenting of anomalous right coronary artery originating from left sinus of valsalva using the Voda guiding catheter: a report of two cases. Indian Heart J. 2001; 53:79e82. 8. Ng W, Chow WH. Successful angioplasty and stenting of anomalous right coronary artery using a 6 French Left Judkins #5guide catheter. J Invasive Cardiol. 2000;12:373e375. Fig. 9 e End result with TIMI III flow. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e44 Please cite this article in press as: Kulkarni A, Ramesh B, Primary PCI in anomalous coronary: Wire first approach, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.005
  6. 6. Apollohospitals:http://www.apollohospitals.com/ Twitter:https://twitter.com/HospitalsApollo Youtube:http://www.youtube.com/apollohospitalsindia Facebook:http://www.facebook.com/TheApolloHospitals Slideshare:http://www.slideshare.net/Apollo_Hospitals Linkedin:http://www.linkedin.com/company/apollo-hospitals Blog:Blog:http://www.letstalkhealth.in/

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