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Primary Angioplasty and Stenting of an Anomalous Coronary Artery for Acute Myocardial Infarction Through the Radial Approach
Interventional cardiologist Philippe GAROT, Chef de Clinique-Assistant
 
Center
Unité de Cardiologie Interventionnelle- Explorations fonctionnelles
Hôpital Henri MONDOR
CRETEIL
History and angiography

A 41-year-old male smoker presented to our catheterization laboratory with a first typical chest pain of 3 hours. Physical examination on admission was unremarkable except for the presence of an increase in jugular venous pressure with inspiration. The ECG on admission showed ST-segment elevation > 0.1 mV in inferior and right precordial leads without Q wave formation. After a bolus administration of abciximab (Réopro®, Lilly-France, Saint-cloud, France), the patient underwent emergency cardiac catheterization through the right radial approach, as routinely performed in our institution 24 hours a day. A bolus of heparin (5000 IU) and verapamil (3mg) was administered in the radial sheath. Abciximab was then administered continuously for 12-H.

Because a selective and stable catheterization of the left main appeared challenging with a 6 French 2 Left Amplatz catheter (Medtronic Interventional Vascular, Minneapolis, Minnesota), it was exchanged for a 4 R Judkins catheter (Medtronic) that revealed the presence of a single coronary ostium The left and right coronary arteries arose from a vertically descending common trunk that bifurcated into an occluded right coronary artery (RCA) and a left anterior descending (LAD) that gave rise to a small left circumflex (LCX) [fig.1.]. There was no evidence of atherosclerosis on the left coronary artery.                                          

Fig.1
Strategy

Stenting
Procedure The RCA occlusion crossed with a 0.014” high torque floppy guide wire (BMW®, Advanced Cardiovascular Systems, Temecula, CA) and the lesion was dilated with a 3 mm Viva® (Boston Scientific/Scimed, Minneapolis, Minnesota) balloon (13 mm long) inflated at 6 atmospheres for 30 seconds. Initial angiographic result showed evidence of dissection along with an intra-coronary thrombus. A 22 mm long tubular stent (Helistent®, Hexacath, Rueil-Malmaison, France) was successfully implanted (10 atmospheres) with the recovery of a TIMI grade 3 flow and no residual stenosis (figure 2.).

Fig.2
Clinical course On 24-hours echocardiographic examination, no thickening was observed in the inferior wall and a significant dilation of the right ventricle (RV) along with an asynchronous contraction of the septal wall characteristic of the RV injury were evidenced. At day-8 examination, the inferior wall function fully recovered with the complete regression of the RV injury. On-site bleeding did not occurred despite aggressive Gp-IIbIIIa inhibitor and anticoagulant therapy. The clinical in-hospital and 6 month outcome was event free.
Comments In the present case report, the anomalous pathway of the RCA with an excessive angulation of the artery or its compression between the aorta and the pulmonary trunk may have provide a severe reduction of coronary blood flow very close from the occlusion site. Indeed, this remain speculative and we cannot exclude that a “classical” mechanism such as plaque rupture and/or de novo thrombosis (especially in a current smoker) may have led to acute coronary occlusion. The present case may also be of interest by underlying the technical aspects of emergency angioplasty procedures in the specific subset of patients presenting with a single coronary artery. In particular, since the left main plunged vertically after its emergence from the proximal ascending aorta closed to the left Valsalva sinus, the selective and stable catheterization of the left main was considered challenging with the use of guiding catheters that are shaped for the left coronary artery (i.e. Left Judkins or Amplatz). Actually, an attempt was made to selectively engage the left main with a 2 L Amplatz guiding catheter because we routinely use this catheter for the catheterization of both left and right coronary arteries during trans-radial interventions (right radial approach). By this way, catheters manipulations are reduced and the procedure is improved through significant saving of time and decrease in radial artery spasm. Finally and fortunately, the occlusion site was distant from the RCA origin thus avoiding for the risk of complete coronary blood flow interruption during balloon inflations. There is not doubt that this could have hampered the procedure outcome.