A patient with anomalous right coronary artery originating from the left anterior descending artery who underwent complex percutaneous coronary intervention: A case report

Abstract

An anomalous right coronary artery (RCA) arising from the left anterior descending artery (LAD) is an extremely rare coronary anomaly. A 71-year-old patient presented with severe exertional angina for 10 days. Coronary angiography revealed that an anomalous RCA originated from the proximal LAD. The anomalous RCA had also critical ostial stenosis and the LAD had a critical lesion before origin of RCA (95%) and chronic total occlusion (CTO) at DII branch level. Furthermore, extremely tortuous circumflex (Cx) artery had critical tandem lesions at the mid portion. Surgical treatment was offered, but the patient refused the surgery. We decided to perform percutaneous coronary intervention (PCI). The first stage of PCI was on Cx artery. Two floppy guide wires were placed into the Cx artery and a long drug-eluting stent (DES) could be placed. Secondly, the LAD CTO lesion could be crossed by Confianza pro 9 wire. After the predilatation, another DES was placed into the LAD CTO region. Then all other significant lesions were successfully treated with PCI in a single session.

<Learning objective: An anomalous right coronary artery (RCA) arising from the left anterior descending artery (LAD) is an extremely rare coronary anomaly. This is the first report of case of a patient with an anomalous RCA originating from the proximal LAD and complex coronary atherosclerosis, who underwent successful complex percutaneous coronary intervention (PCI) in a single session. PCI may be an alternative treatment choice to surgery, especially in patients with high surgical risk and complex coronary anatomy.>

Introduction

The incidence of an anomalous coronary artery is approximately 1% in the general population [1], [2]. An anomalous right coronary artery (RCA) which originated from the left anterior descending artery (LAD) is rarely seen and has previously been considered a variant of a single coronary artery [1]. Most patients with such an anomaly in the literature were asymptomatic and had no predisposition to developing coronary atherosclerosis [3], [4], [5].

In this report, we present a case of a patient with anomalous RCA origin and symptomatic stenosis in all major epicardial coronary arteries and who was successfully treated with percutaneous coronary intervention (PCI) in a single session.

Case report

A 71-year-old male patient with hypertension, hyperlipidemia, and chronic obstructive pulmonary disease was admitted to our hospital due to severe exertional angina. He had undergone coronary angiography twice due to stable angina pectoris in 2004 and 2009. In the first angiogram, RCA origin anomaly which originated from the proximal LAD just near the first septal perforator, critical LAD lesion before the origin of RCA (90%), and moderate aortic stenosis with normal left ventricular (LV) function (ejection fraction: 62%) were detected. The combination of coronary artery by-pass graft (CABG) + aortic valve replacement (AVR) surgery had been advised to the patient, but he had refused surgery. Five years later, coronary angiography had been again performed due to an increase in frequency and severity of angina. According to the second angiogram which showed atherosclerotic progression, the anomalous RCA also had critical ostial stenosis (70%) and the LAD had critical lesion before origin of RCA (95%) and chronic total occlusion (CTO) at DII branch level. Furthermore the circumflex (Cx) artery had critical stenosis at the mid portion (70%). Again CABG + AVR had been offered to the patient, but he had refused surgery. The patient had been discharged on optimal medical therapy (aspirin, amlodipine, metoprolol, long acting oral nitrate, ivabradine, and statin). Despite full-dose antianginal therapy, the patient was admitted to our hospital due to Canadian Cardiovascular Society (CCS) Class III angina pectoris and dyspnea during everyday living activities for 10 days. The electrocardiogram on admission showed sinus rhythm and LV hypertrophy pattern. Physical examination was normal except a grade 3 of 6 systolic ejection murmur over the aortic area. Laboratory tests were performed. The values of hemoglobin (14.6 g) and creatinine (1.0 mg/dL) were normal on admission. Serial measurements of cardiac markers were within the normal range. A transthoracic echocardiographic examination showed moderate aortic stenosis (mean gradient: 28 mmHg; peak gradient: 53 mmHg; and aortic valve area: 1.2 cm²), LV hypertrophy, mild hypokinesia in the anterior wall, and mild LV systolic dysfunction. The LV ejection fraction was calculated as 44%. All LV regions were viable on myocardial perfusion scintigraphy.

The patient underwent coronary angiography after 16 h. The coronary angiography confirmed the anomalous RCA which originated from the proximal LAD just near the first septal perforator and revealed significant stenosis at the RCA ostium (Fig. 1, Fig. 2, Fig. 3 and Video 1). Furthermore, the LAD had significant stenosis before RCA ostium and CTO at the mid level (Video 2). The Cx artery was extremely tortuous and had also significant tandem lesions (Fig. 2). We advised the combination of CABG + AVR surgery to the patient, but he refused surgery. Then we decided to perform percutaneous coronary intervention (PCI) and chose a 7 French extra back-up guiding catheter via right femoral access. The first stage of PCI was on the Cx artery. The floppy guide wire could cross the tandem lesions in the Cx artery which was extremely tortuous. A second floppy guide wire was placed into the Cx artery as a buddy wire. After the predilatation, an Endeavor stent (2.5 mm × 28 mm; Medtronic, Minneapolis, MN, USA) could cross the lesion and was successfully deployed (Videos 3 and 4). Secondly, we attempt to cross the LAD CTO lesion. We chose an over-the-wire balloon (Apex push 1.5 × 15; Boston Scientific, Natick, MA, USA) and Fielder XT wire. But Fielder XT was sliding into the diagonal branch and failed to cross. Then we changed Fielder XT with Confianza pro 9 and the occlusion could be easily crossed by Confianza pro 9 wire (Video 5). The over-the-wire balloon could also cross the occlusion and Confianza pro 9 was exchanged with a floppy guide wire. After the predilatation (Video 6), another Endeavor stent (2.5 mm × 24 mm) was deployed (Video 7). Then, another Endeavor stent (2.75 mm × 18 mm) was successfully deployed into the ostium of anomalous RCA (Video 8). Finally, a Xience V stent (3.0 mm × 13 mm; Abbott, Abbott Park, IL, USA) was positioned and deployed in the proximal LAD (Video 9). After the post-dilatation with non-compliant balloon, the procedure was ended (Video 10). Total contrast volume was 335 mL and total fluoroscopy time was 46.8 min. The patient was discharged 2 days later without any problem and dual antiplatelet therapy (aspirin + clopidogrel) was prescribed for at least 12 months. The patient was well and asymptomatic at 6-month follow-up.

Fig. 1.

Anteroposterior cranial view of coronary angiography demonstrates right coronary artery originating from left anterior descending coronary artery (LAD) (dark arrow shows the LAD chronic total occlusion lesion, white arrow shows atherosclerotic lesion in the proximal LAD just before the ostium of anomalous right coronary artery).

Fig. 2.

Lateral view of coronary angiography demonstrates right coronary artery originating from left anterior descending coronary artery and atherosclerotic lesions in the ostium of right coronary artery and mid portion of circumflex artery (white arrows show severe tandem atherosclerotic lesions in the mid portion of circumflex artery, dark arrow shows atherosclerotic lesion in the ostium of anomalous right coronary artery).

Fig. 3.

Lateral view of coronary angiography showed the critical lesion at the ostium of anomalous right coronary artery.

Supplementary material related to this article found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2013.03.012.

Video 1

Right coronary artery originating from the proximal left anterior descending artery with a significant stenosis at the ostium.

Video 2

Left anterior descending artery with a significant stenosis before the right coronary arteryostium and totally occluded at the mid level.

Video 3

An Endeavor stent (2.5 mm × 28 mm) prepared for the lesion in the circumflex artery.

Video 4

Circumflex artery after stenting.

Video 5

Crossing the totally occluded left anterior descending artery lesion with a Confianza pro 9 wire.

Video 6

Advancement of the over-the-wire balloon through the totally occluded left anterior descending artery lesion.

Video 7

Stenting the left anterior descending artery lesion.

Video 8

Stenting the right coronary arteryostium.

Video 9

Positioning and deployment of a Xience V stent (3.0 mm × 13 mm) in the proximal left anterior descending artery.

Video 10

Final angiography after post-dilatation with non-compliant balloon.

Discussion

The incidence of coronary artery anomalies in the literature varies from 0.3 to 1.3% [2], [5], [6]. The coronary anomalies are increasingly reported with the development of cardiac imaging techniques. The largest angiographic series of more than 125,000 patients by Yamanaka et al. [2] reported 1.3% incidence of anomalous coronary artery. In this series, the most common anomaly was a separate origin of the LAD and Cx, with an incidence of 0.41%, followed by the Cx arising from the RCA, with an incidence of 0.37%. In a series of 13,010 patients, Topaz et al. [6] reported a 0.61% incidence of anomalous coronary artery. In this study, separate origin of the LAD and Cx was not considered an anomaly and the most common anomaly was anomalous origin of the RCA, with an incidence of 0.38% [6].

A variety of anomalous origin of the RCA has been reported, including the left anterior sinus with variable courses, ascending aorta above the sinus level, descending thoracic aorta, left main coronary artery, circumflex coronary artery, the pulmonary arteries, or below the aortic valve [7]. The origin of the RCA from the LAD is rare in the literature and considered to be a variant of a single coronary artery [1]. In a large series of 13,010 adult patients, 80 (0.61%) patients had anomalous coronary circulation, out of which 50 (0.37%) had anomalous origin of RCA, and only 1 (0.008%) from left coronary artery [5]. In our patient RCA originated from the proximal LAD just near the first septal perforator.

Most of these anomalies are considered benign and have no predisposition to developing coronary atherosclerosis [3], [4], [5]. But a number of those patients may exhibit ischemic symptoms. Most of these symptoms result primarily from the stenosis in the LAD or rarely in the RCA [8], [9], [10]. In our patient, the RCA originated from the proximal LAD just near the first septal perforator. Despite full-dose antianginal therapy, the patient had severe exertional angina pectoris (CCS Class III). Our patient also had severe coronary atherosclerosis with challenging anatomy for PCI and moderate aortic stenosis. We recommended surgery, but the patient refused surgery due to the high risk. Therefore, we decided to perform PCI. The challenging points for PCI in this patient were anomalous RCA, RCA ostial lesion, extremely tortuous Cx, critical LAD lesion before RCA ostium, and LAD CTO at the mid level. All critical lesions, including LAD CTO, were successfully treated with PCI in a single session. The patient was discharged 2 days later without any complication.

The anomalous RCA which originated from the LAD is rarely seen. Most patients with such anomaly in the literature were asymptomatic and had no critical coronary stenosis [3], [4], [5]. The combination of those anomalies and symptomatic coronary atherosclerosis had been reported in a few patients and surgical treatment had been performed on those patients in previous reports [8], [9], [10]. In such patients, surgery is the first choice of treatment. This is the first report of a patient with an anomalous RCA originating from the proximal LAD and complex coronary atherosclerosis, who underwent successful complex PCI. In our patient, all major epicardial arteries had significant atherosclerotic stenosis and challenging points for PCI. Complex PCI could be successfully performed in a single session.

Conclusion

This is the first report of a case of a patient with an anomalous RCA originating from the proximal LAD and complex coronary atherosclerosis, who underwent successful complex PCI in a single session. PCI may be an alternative treatment choice to surgery, especially in patients with high surgical risk and complex coronary anatomy.