|Year : 2021 | Volume
| Issue : 3 | Page : 188-190
Right coronary artery intervention through right radial access in a patient with aberrant right subclavian artery and anomalous origin of right coronary artery
Barun Kumar1, Shishir Soni1, Anupam Singh2
1 Department of Cardiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||27-Jun-2021|
|Date of Decision||04-Oct-2021|
|Date of Acceptance||26-Oct-2021|
|Date of Web Publication||22-Dec-2021|
Dr. Shishir Soni
708, SR/JR Hostel, All India Institute of Medical Sciences, Veerbhadra Road, Rishikesh - 249 201, Uttarakhand
Source of Support: None, Conflict of Interest: None
We report a case of primary angioplasty of right coronary artery (RCA) through right radial artery access in a patient with aberrant right subclavian artery (arteria lusoria) and anomalous origin of RCA. Major challenges in such cases are difficulty in hooking coronary ostia and getting enough support from the guide catheters. However, another challenge confronted in this patient was the anomalous origin of RCA from the left sinus. Herein, we discuss key aspects of management in this scenario. Arteria lusoria with anomalous RCA can be confronted during the transradial intervention. Use of an appropriate guide catheter to facilitate the procedure in this scenario can help interventionists to manage such a situation, and this can be a useful alternative in those patients with unfavorable transfemoral access along with this rare anomaly.
Keywords: Anomalous right coronary artery, arteria lusoria, percutaneous coronary intervention
|How to cite this article:|
Kumar B, Soni S, Singh A. Right coronary artery intervention through right radial access in a patient with aberrant right subclavian artery and anomalous origin of right coronary artery. Heart India 2021;9:188-90
|How to cite this URL:|
Kumar B, Soni S, Singh A. Right coronary artery intervention through right radial access in a patient with aberrant right subclavian artery and anomalous origin of right coronary artery. Heart India [serial online] 2021 [cited 2022 Jan 28];9:188-90. Available from: https://www.heartindia.net/text.asp?2021/9/3/188/333295
| Introduction|| |
Nowadays, coronary intervention using a transradial approach is commonly done and preferred. However, with a transradial approach, anatomical hurdles in the path are not uncommon. Among various such situations, arteria lusoria is one which creates hindrances in passing the wire and guide catheter. Thus, using a guide catheter which can easily pass through arteria lusoria and provide adequate support during percutaneous coronary intervention (PCI) may be a useful option. Moreover, if anomalous origin of right coronary artery (RCA) is present in such cases, then PCI in such an extreme combination requires multiple attempts to hook coronary ostia that steal extra time resulting in delay in revascularization, increased use of contrast, and more radiation exposure. Selection of an appropriate guide catheter is the key in such difficult situations. However, left transradial access or transfemoral access are available alternatives rather than struggling with the right transradial access.
| Case Report|| |
A 60-year-old hypertensive, nondiabetic male presented with 4 h of chest pain. General physical examination revealed pulse rate 62 per min, blood pressure 98/66 mm of Hg, and respiratory rate of 22 per min.
Examination of the cardiovascular system revealed normal heart sounds, and respiratory system examination was normal. The electrocardiogram done immediately showed >2 mm elevated ST segment in inferior leads. Transthoracic echocardiography suggested hypokinetic basal inferior and basal inferoseptal area with moderate left ventricle dysfunction.
The patient was given a loading dose of dual antiplatelet and immediately shifted to the cath laboratory for primary PCI. Under all aseptic precaution, the radial artery puncture was made, followed by insertion of 6-French introducer sheath with the help of guidewire. Spasmolytic solution containing nitroglycerine and diltiazem was given through the introducer sheath, followed by 5000 IU of heparin. Tiger catheter (5F) with Terumo wire was advanced through the introducer sheath, but it was difficult to pass them into ascending aorta due to acute lusoria angle as the Terumo wire was entering into the descending aorta instead of entering ascending aorta [Figure 1]a. After several attempts, the wire finally crossed the lusoria angle. The Tiger catheter advanced further but again required several attempts to reach the ascending aorta but failed to hook the RCA ostium. Thus with the help of nonselective contrast injection, anomalous origin of RCA from the left sinus of Valsalva was suspected. Finally, anomalous RCA was hooked and then the diagnostic angiogram was performed which revealed simultaneous filling of left main coronary artery and its branches and significant stenosis in the mid-RCA [Figure 1]b. Decision for angioplasty and stenting was taken, but most challenging was to select a guide catheter which could advance through acute lusoria angle to enter ascending aorta and catheterize RCA along with adequate backup support while performing PCI. Looking into the challenging shape, anomalous origin of RCA, and requirement of backup support, extra backup (EBU) guide catheter was taken, and surprisingly, it was done uneventfully [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f.
|Figure 1: (a-f) Guidewire entering into ascending aorta through arteria lusoria with an acute angle (a), despite initial passage of guidewire into ascending aorta further push leading to entry of guidewire into descending aorta (b), Right coronary artery angiogram taken with extra backup EBU 3.5 6F guide catheter (c), wire crossing lesion in right coronary artery with good backup support from extra backup catheter (d), Extra backup catheter in stable position through acute lusoria angle (e), successful angioplasty and stenting done timely with the help of extra backup catheter (f)|
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The patient had an uneventful hospital course and was discharged on day 2 on optimized medical treatment.
| Discussion|| |
Increasing number of transradial angiograms are being performed nowadays because of patient's comfort and low risk of complications. However, procedure failure and change to femoral access can occur due to various factors and one of them is arteria lusoria, which is confronted in <2% of cases.
Arteria lusoria is an uncommon condition, in which the brachiocephalic trunk is absent and four large arteries, namely subclavian and common carotid (right and left), arise directly from the arch of the aorta with aberrant right subclavian artery having distal left-sided origin and retroesophageal course. It is usually asymptomatic and is diagnosed either in symptomatic cases or incidentally during investigations such as computed tomography and during transradial coronary angiography.
This congenital variant is suspected during transradial coronary angiography when guidewire enters into the descending aorta instead of entering into the ascending aorta as in our case, which is due to the acute angle created by aberrant right subclavian artery with the aorta, requiring the wire and catheter to arc back to enter ascending aorta.
When this situation is confronted, the risk of procedure failure is high, requiring change in the access to the transfemoral route which steals extra time as well as discomfort to the patient. In patients requiring primary PCI, this extra time conceded in performing the procedure can lead to many complications such as increased risk of arrhythmia, heart failure, and cardiac arrest.
While performing successful primary PCI in these patients, one has to deal with several challenges. First is to advance wire and catheter into ascending aorta which is difficult due to acute lusoria angle. In most of the cases, wire enters into the descending aorta instead of entering into ascending aorta. For managing this, a stiffer wire can be used; however, advancing guide catheter is still difficult as it abruptly enters descending aorta while crossing acute lusoria angle and sometime disengages the wire also. In our case also, this problem occurred while performing a diagnostic angiogram with Tiger catheter; however, during PCI with EBU catheter, probably because of its shape, it was easily advanced into the ascending aorta.
Second is selective catheterization of the RCA, for which selection of appropriate guide is the major challenge in this scenario, as this is almost impossible with Judkins right (JR) catheter and Amplatz right catheter. With JR catheter, several attempts may be required because its primary curve is fixed; therefore, it intubates only a small segment of ostium; moreover, a catheter may not be coaxial with the RCA, thus even if catheterization is done, it may not provide adequate support. For managing this particular problem, Amplatz left (AL) and EBU can be a good option. If AL catheter enters ascending aorta by using stiffer wire, then for the remaining procedure, it can be a good alternative as it provides deep engagement into the coronary and better support while performing PCI. However, in this patient, both of these challenges, i.e., crossing the acute lusoria angle and selective catheterization of anomalous RCA with adequate support, were done easily with an EBU catheter. One possible reason could be the origin of RCA from the left sinus close to the origin of the left main coronary artery and at the same level, thus favoring a catheter which is more commonly used for catheterizing the left system.
Third is advancing wires, balloons, and stents through a guide catheter which could provide adequate support without disengaging from coronary ostium till the procedure is completed. Therefore, prerequisites for a guide catheter are better support, perfect coaxiality, and ability to fix the tip of catheter into the ostium of the RCA, thus contributing to a stable position and thus less likely to dislodge the guiding catheter.
These difficulties tend to increase the number of catheters used and prolong procedural duration along with increased use of contrast and more radiation exposure. The procedural duration of angioplasty in a patient with arteria lusoria is prolonged in most of the case reports as compared to the usual procedure without this defect. The use of an EBU catheter has never been advocated previously for this scenario. However, the use of an EBU catheter in catheterizing anomalous RCA has been described previously in some studies. In this scenario, there were three major hurdles that had been encountered well by the selection of an appropriate guide catheter. However, more studies are required to further enlighten the facts related to performing successful transradial coronary intervention in patients with this rare combination of anomalies. Other available alternatives to counter arteria lusoria are left transradial access and transfemoral access.
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.
Informed consent was obtained from the patient. Patient anonymity has been maintained.
BK,SS: Concept, design, definition of Intellectual content. SS,AS: Literature search, data acquisition. BK,SS,AS : Analysis, Manuscript preparation, Editing and Manuscript review.
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Conflicts of interest
There are no conflicts of interest.
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