Retrograde coronary intervention for chronic total occlusion of RCA ostium with anomalous origin: A case report

Abstract

Chronic total coronary occlusion (CTO) remains one of the most technically challenging clinical scenarios in which to perform interventions. Although the antegrade approach is a general approach for CTO recanalization, a retrograde attempt improves the success rate and its usage has been increasingly adopted in recent years. Congenital coronary anomaly represents another technically challenging factor especially when accompanied with CTO lesions. We report the case of a 43-year-old man with no relevant cardiac history who presented for evaluation of exertional chest discomfort with palpitation. Coronary angiography revealed the existence of CTOs at just ostial of anomalously originating right coronary artery (RCA) with no angiographic ostial dimple in Valsalva sinus. Because it was not possible to engage with the antegrade guiding catheter (GC) at the inlet of the RCA, we decided to perform revascularization using the retrograde approach. Percutaneous coronary intervention (PCI) of such an anomalous RCA, which is chronically occluded, is difficult and is rarely described. Retrograde approach has been used to overcome the impossible placement of antegrade GC to RCA ostium. After successful CTO-PCI, his chest discomfort promptly disappeared. <Learning objective: Percutaneous coronary intervention for chronic total coronary occlusion of anomalous origin of right coronary artery (RCA) patients is difficult and is rarely described. Retrograde approach has been used to overcome the impossible placement of antegrade guiding catheter to RCA ostium.>.

Keywords: Anomalous origin of coronary artery; Case report; Chronic total occlusion; Percutaneous coronary intervention.

Fig. 1

(A) Screening coronary computed tomography suggested anomalous origin of right coronary artery (RCA) from ascending aorta above commissure level between left and right coronary cusp. There seemed to be no obvious stenosis in RCA running through inter-arterial course. (B) Aortography showed chronic total occlusions at just ostial of anomalous originating RCA with no angiographic ostial dimple in Valsalva sinus.

Fig. 2

(A and B) A guiding catheter was engaged in the left coronary artery and a guidewire was selected into the 2^nd septal branch. (C) Selective contrasting was performed in a retrograde manner from the central portion of the right coronary artery (RCA) to confirmed chronic total occlusion at RCA ostium. (D) The retrograde guidewire with extension was captured, pulled back and forth to insert the tip into the antegrade guiding catheter by using a snare. (E) Stent was placed in proximal RCA. (F) Antegrade flow in RCA with anomalous origin from left coronary sinus was observed after stenting.

Fig. 3

(A) Follow-up coronary computed tomography revealed right coronary artery (RCA) with anomalous origin from left coronary sinus. A stent observed in ostial RCA (orange arrow). (B) A stent (orange arrow) was observed in ostial RCA between the aorta and pulmonary artery without any obvious stenosis. [Left panel: including pulmonary artery (yellow asterisks), Right panel: excluding pulmonary artery].