Taming of the Hydra – percutaneous coronary intervention of a single coronary artery arising from the right sinus of Valsalva

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @coscardio

Clinical presentation

An 86-year-old male, with a history of type 2 diabetes mellitus and ex-smoker, presented with crescendo angina. High sensitivity troponin I was <10ng/L. He developed ST segment elevation on a modified Duke exercise stress test at a low work load and was taken for coronary angiography.

Case management

Coronary angiography revealed a high-grade stenosis of the proximal left anterior descending (LAD) coronary artery arising from an anomalous single coronary artery from the right sinus of Valsalva (Video 1).

Following a multidisciplinary heart team discussion, it was decided to proceed with percutaneous coronary intervention (PCI) to the LAD.

Right radial vascular access with a 7Fr long Glidesheath was selected. A 7Fr JR4 guiding catheter was chosen after a 7Fr Multipurpose guiding catheter failed to selectively engage the “right main” ostium.

An Asahi Sion Blue wire was placed in the distal right coronary artery to stabilize the guide catheter. The LAO caudal view was the optimal working projection.

The anomalous LAD from the “right main” had an acute 90-degree take-off and an Asahi Sion Blue was unable to cross the lesion owing to continuous prolapse of the wire from the LAD into the right coronary artery (Video 2). The patient developed sudden onset of 8/10 chest pain following the first attempted wiring episode. The chest pain persisted despite 5mg morphine given intravenously.

A Supercross 120-degree microcatheter was then selected and a Pilot 50 wire was successfully maneuvered across the proximal LAD lesion into the distal LAD with the support of the microcatheter (Video 3).

The lesion was then predilated with a 1.25x15mm and then 1.5x15mm Ryurei balloons followed by Minitrek 2.0x20mm balloon. The chest pain had resolved following predilation. Intravascular ultrasound (Refinity 45MHZ, Philips Volcano) pullback was performed and revealed a fibrocalcific plaque (Video 4).

A 3.5x15mm non-compliant balloon was used to predilated the lesion and thereafter an Orsiro 4.0x15mm drug eluting stent was implanted at 10 atm. The stent was post-dilated with a 4.0x12mm non-compliant balloon with 18 bar. IVUS pullback revealed excellent stent apposition (Video 5) and there was a very satisfactory angiographic result (Video 6).

Author

Crochan O'Sullivan

@coscardio

Interventional cardiologist / Cardiologist

Cork, Ireland

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