Author + information
Patient Initials or Identifier Number
Mr. P / 12619261
Relevant Clinical History and Physical Exam
A 73 year-old male presented with spontaneous typical chest pain for 48 hours prior admission, with cold sweat. He has prior history of tobacco smoking and hypertension, but denied diabetes. Upon admission, he was diaphoretic but clearly conscious. BP90/60, HR 50x/m RR 20x/m, other physical exam documented normal findings.
Relevant Test Results Prior to Catheterization
ECG revealed sinus rhythm with total AV Block and junctional escape rhythm with ST elevations at inferior, right ventricular, posterior leads. Troponin 14.9, CKMB 110.8, Ureum 47, serum creatinine 1.87
Relevant Catheterization Findings
Left Main : normal
Left Anterior Descending : 80% stenosis at proximal LAD
Left Circumflex : Normal
Right Coronary Artery : Anomalous ostium RCA side to side with ostium LMCA, significant 80% stenosis at proximal RCA, critical stenosis at mid RCA, 80% stenosis at distal RCA, 70% at RPDA, collateral grade II from LCx
After TPM insertion and CAG, the procedure started with cannulation of RCA ostium with Judkins right guiding catheter (GC) 4.0 5F, but we found difficulty to engage. We changed the GC with JR 3.5 5F but still couldn’t engage. Then we changed with Multipurpose catheter 5F, but It failed to engage. Finally, we could engage the ostium RCA with GC Amplatz Left 0.75 6F and found the ostium was located at adjacent and side by side with the ostium of LMCA, arising from left coronary sinus. After securing the support with GC AL 0.75 6F, we proceeded with wiring attempt using guiding wire Whisper through distal RCA. After successful wiring, we predilated with Sapphire balloon 1.5 x 15 mm at mid RCA up to 15 atm/7”. We proceeded with Sapphire balloon 2.25 x 15 mm at mid RCA up to 15 atm/7’’, at distal RCA predilated upto 6 atm for 6’’ with the improvement of in distal flow. We administered 0.4 mg nitrate intracoronarily. After the occlusion successfully crossed, we delivered overlapping stents. We deployed DES XLIMUS (Sirolimus) 2.5 x 28 mm to distal RCA, 15 atm/7", post dilated 15atm/7", XLIMUS (Sirolimus) 2.5 x 12 mm to mid RCA, overlapping with the distal stent, dilated 18atm/7", post-dilated 18 atm/5", DES XLIMUS (Sirolimus) 3.0 x 28 mm to proximal RCA, dilated 14atm/9", post dilated 14 atm/7". Final angiography showed Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow and no residual thrombus.
Occlusion of an anomalous RCA arising from the left coronary sinus is a rare cause of acute inferior wall MI. Comprehensive anatomical knowledge about the course of aberrant artery, selecting appropriate equipment, selective engagement of anomalous artery, and specific angioplasty technique are important keys for successful procedure in these cases.