|Year : 2021 | Volume
| Issue : 3 | Page : 157-160
Shepherd' Crook right coronary artery in an octagenerian: A case report and literature review
Debasish Das, Debasish Acharya, Anindya Banerjee, Tutan Das, Subhas Pramanik
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||26-Jul-2021|
|Date of Decision||12-Sep-2021|
|Date of Acceptance||21-Oct-2021|
|Date of Web Publication||22-Dec-2021|
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
Right coronary artery after origin from right coronary sinus traverses horizontally to run in right atrioventricular groove till the crux of the heart where it divides into posterior descending artery and posterior left ventricular branch. When the right coronary artery after its origin takes an acute high take off from the ostium and then abruptly descends down making a hairpin loop to run in the right atrioventricular groove, it is known as Shepherd's crook right coronary artery which is extremely rare to encounter in routine clinical practice. This interesting coronary artery deformity has great significance per se so far as the coronary physiology and intervention is concerned. We present a case of Shepherd's crook right coronary artery in the most elderly patient of 84 years of age in world literature and detailed review of this peculiar anatomy. Review literature about Shepherds Crook deformity is yet not there in the literature except some case reports and this review article will be providing the interventional cardiologists a detailed insight into the right coronary ischemia secondary to this interesting anomaly.
Keywords: Right coronary artery, Shepherd Crook, Octagenerian
|How to cite this article:|
Das D, Acharya D, Banerjee A, Das T, Pramanik S. Shepherd' Crook right coronary artery in an octagenerian: A case report and literature review. Heart India 2021;9:157-60
|How to cite this URL:|
Das D, Acharya D, Banerjee A, Das T, Pramanik S. Shepherd' Crook right coronary artery in an octagenerian: A case report and literature review. Heart India [serial online] 2021 [cited 2022 May 16];9:157-60. Available from: https://www.heartindia.net/text.asp?2021/9/3/157/333296
| Introduction|| |
A Shepherd's Crook [Figure 1] right coronary artery is characterized by a tortuous and high course usually just after its origin from the aorta. The prevalence of Shepherd's Crook right coronary artery (RCA) in general population is estimated to be around 13%. This interesting variant many often does not carry clinical significance but complicates the coronary intervention. It is often difficult to engage this anomaly with routine Tiger or Judkins right (JR) catheter during coronary intervention. During coronary intervention guide catheter stability becomes an issue and passing the coronary stents and balloon across this high take off with 180° turn becomes an issue. We present a case and detailed insight into this interesting anomaly known since ages and is a matter of curiosity till date.
| Case Report|| |
An octagenerian (84-year female) nondiabetic, nonhypertensive, and dyslipidemic presented to the cardiology outpatient department with rest angina since the last 16 h with diaphoresis and shortness of breath. During presentation her blood pressure was 100/60 mmHg in right arm supine position and had pulse rate of 62 beats/min. Cardiovascular system examination revealed the presence of left ventricular fourth heart sound (LV S4). Electrocardiography revealed the presence of acute inferior wall ST elevation myocardial infarction. Echocardiography revealed the presence of regional wall motion abnormality in the form of hypokinesia in the inferior posterior wall with the presence of mild ischemic mitral regurgitation with mild LV systolic dysfunction (EF 46%). In view of ongoing angina, she was taken for right transradial coronary intervention. Left coronary injection was normal. Right coronary injection revealed acute high take off with abrupt down ward turn of RCA interestingly known as Shepherd's Crook deformity of RCA [Figure 2] and [Figure 3]. Interesting part of intervention was that we could engage this anomaly with conventional Tiger and JR catheter but with an unusual loop. There was difficulty in negotiating the stent across the 180° angle bend, for which we deployed two conventional balanced middle weight coronary wires in the right coronary artery (buddy wire technique) which straightened the angle and provided extra support for further negotiation of stent. We deployed a 3 mm × 15 mm drug-eluting stent across the distal RCA lesion and achieved thrombolysis in myocardial infarction III flow. The patient was discharged with dual antiplatelets in the form of aspirin 75 mg and ticagrelor 90 mg twice daily with high-dose atorvastatin 80 mg and ramipril 1.25 mg with advice to follow-up after 1 month. Computed tomography coronary angiogram revealed the 180° U loop of the Shepherds Crook deformity [Figure 4]. This interesting anomaly always poses some problem during coronary intervention and needs to be properly handled to curtail the risk of complications during intervention.
|Figure 3: Proximal part of the right coronary artery runs upwards in Shepherds crook RCA (Lateral view)|
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|Figure 4: Computed tomography angiogram showing the 180° U turn of Shepherd Crook RCA|
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| Discussion|| |
Shepherd's Crook deformity of the right coronary artery is considered as a hemodynamically nonsignificant anomaly, but interestingly, in some cases, it is associated with obstructive coronary artery disease (CAD) as noted in our case, that is in an octagenerian to be reported first in world literature. Saglam et al. described Shepherd Crooks RCA can have atherosclerotic plaque in 24.3% of cases as noted in our case who had critical obstruction before the crux, age, and dyslipidemia may be the contributing factors behind the development of atherosclerotic plaque in the afore said patient. Saglam et al. divided the Shepherds Crook RCA into two types: type 1 which courses inferiorly with an angle of equal to or more than 90° and Type II which courses inferiorly with an angle <90°. The illustrated coronary artery goes downward with an angle of more than 90° (almost a 180° turn) or belongs to Saglam Type 1. Singh et al. described a case of Shepherd crook RCA presenting with non-ST elevation myocardial infarction with completely occlusive thrombus of right coronary artery. They engaged this RCA deformity with AL2 guide catheter and were able to cross the 180° turn of the anomaly with Whisper Extra support wire with three curves. These 180° turn of crook RCA poses a challenge during negotiation of wire, balloon, and stent during percutaneous coronary intervention. Pandey et al. also described Shepherd's Crook deformity of the conal artery and described the increased incidence of dissection and abrupt closure during coronary intervention of those cases with Shepherd's crook deformity. Dubey et al. described a case of spontaneous dissection of shepherd crook RCA presenting as acute coronary syndrome in a 69-year-old male in whom dissection was directly stented, and the anomalous RCA was engaged with the routine JR 6F guide catheter. Technical issues during intervention are as follows;
- There is a very high probability of guide catheter-induced dissection or spasm most commonly while forcibly trying to track or remove old balloons and hard wires
- Passing old wires through the acute bend is often challenging
- Tracking new balloons and stents through the 180° turn is also vexing
- Possibility of concentrina is high here which may mimic dissection or spasm
- Rewiring through the bend and the strut is most challenging.
The rule during the coronary intervention is that the wire should be given a U curve at the tip to cross the lesion. A low-profile balloon, i.e. a 1.5 mm balloon should always be taken to cross the bend and predilate the lesion if needed. If tracking of the balloon becomes an issue, buddy wire technique should be adopted to track the balloon. One should never force the wire during shepherd crook intervention as there lies a very high risk of perforation of the distal coronary artery. Most of the Shepherd Crook RCA can be engaged with Amplatzer left (AL) type catheter, and in case of failure of cannulation with AL, Ikari left works. IMA catheter also helps during difficult cannulation. Terashita et al. concluded chronic total occlusion intervention in Shepherd Crook RCA is quite difficult, it may require a bidirectional approach both antegrade and retrograde, guideliners may be helpful during negotiation of hardwires in those cases. Gossman et al. concluded the success rate of percutaneous intervention in Shepherd Crook RCA is somewhat lower as compared to anatomically normal RCA (86% vs. 98%) and the incidence of procedural difficulties are quite higher (33% vs. 13%). Stauber et al. reported the formation of a Rota gutter during attempted rotational atherectomy in a case of shepherd crook RCA, they advised rotational atherectomy in Shepherd Crook RCA should not be attempted at best. Kagiyama et al. reported a case of coronary artery stent dislodgement and aortic dissection during intervention of a Shepherd Crook RCA. Severe tortuosity and angulation of the Shepherd Crook deformity were the cause behind stent dislodgment and they also described there is high probability of twirling of buddy wire in cases with Shepherd Crook RCA. Guidezilla catheter or the mother and the child technique may be helpful for the negotiation of coronary hardwires during difficult percutaneous intervention. The use of guide extension catheters such as Guideliner or Heart Rail may be promising during Shepherd Crook intervention as they provide extra support and make the hair pin or U loop of the Shepherd Crook RCA straighter. Ihdayhid et al. described iatrogenic spiral coronary artery dissection from ostium of the right coronary artery till mid posterior descending coronary artery in a 48-year-old male with Shepherd Crooks RCA where the true lumen was rewired with guidance of IVUS. Muraca et al. described a case of stent fracture with subsequent aneurysm formation and stent thrombosis in a case of Shepherd Crook RCA in a 77-year-old male with Inferior wall ST elevation myocardial infarction. We report the cases of Shepherd Crook RCA in the most elderly person in world literature at the age of 84 years. Coronary intervention in Shepherd Crooks RCA always remains challenging, preferable use of Amplatzer Left (AL) guide catheter, giving a hair pin curve to the guide wire tip or giving three curves, buddy wire technique, initial use of a smaller balloon, avoiding use of old balloon and guidewires, use of smaller stents, and avoiding rota ablation are some of the clues to accomplish successful intervention and avoiding complications.
| Conclusion|| |
The interesting Shepherd Crooks RCA described since ages till remains a challenge when percutaneous coronary intervention is concerned. Although it does not predispose to the increased risk of atherosclerotic obstructive CAD, cases with critical CAD have been described along with the expected complications during the intervention. Proper choice of guide catheter, giving a prerequisite shape to the tip of the guide wire, use of buddy wire technique, mother and child catheter, guide catheter extension, use of low profile ballon and stents, avoiding undue push and pull during intervention, avoiding rota ablation are some of the clues to accomplish successful intervention and avoiding associated complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Institutional Ethical Committee (IEC) approval has been obtained.
- Debasish Das: Final Manuscript Editing
- Debasis Acharya: Manuscript preparation
- Anindya Banerjee, Tutan Das: Literature Search
- Subhas Pramanik: Image Editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]