AB

Mr AB is a 78 years old man with type 2 diabetes and dyslipidaemia. He actively cycles 80km per week and regularly does a 10km run. He presented with a one-month history of progressively reduced effort tolerance and chest pain on exertion. On examination, he is generally well with normal vital signs. Cardiovascular and respiratory examinations were unremarkable.

His haemoglobin was 14.4 g/dL, low density lipoprotein of 4.0 mmol/L, eGFR of 64ml/min/1.73m²  and HbA1C of 6.9%. His electrocardiogram showed left ventricular hypertrophy with diffuse ST segment depression and AVR ST elevetion. Echocardiogram showed left ventricular ejection fraction of 48% with hypokinetic over mid to apical posterior, anterior, lateral and septal.

Diagnostic catheterisation showed diffuse disease in left anterior descending artery (LAD) with severe stenosis at the mid LAD and diffuse disease at distal left circumflex (LCx). There are collateral vessels to the right coronary artery (RCA) from the septal branch. The RCA arose from left coronary cusp, diffusely disease with chronic total occlusion at distal RCA.
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Trial of engagement to the anomalous RCA with JR 3.5 6Fr andAL0.75 6Fr via right radial artery was unsuccessful. Using LAO view, we manage to bring the JL 4.0 6Fr close to the ostium of anomalous RCA. Sion blue wire was used to wire down from outside to the cap of RCA CTO. Finecross microcatheter was inserted into RCA over the sion blue wire to act as an anchor. With finecross support, the JL guiding was successfully pushed and engaged in a power position. Dual puncture techniques was used. JL 3.5 diagnostic catheter was engaged into the left system. Finecross was advanced to the cap of CTO. Wire exchanged to Fielder XTR. The CTOlesion was successfully crossed with Fielder XTR. Finecross was successfully advanced across the CTO lesion. Wire exchanged back to sion blue. Lesion was predilated with 2.0/12 and 2.5/15 semi-compliance balloon at the mid and distal RCA. The proximal lesion was predilated with NC 3.5/15. 2.75/38 stent and3.5/20  stent was deployed to the mid RCAand proximal RCA respectively. Post dilatation was performed to the mid and proximal RCA stent with NC 3.5 and NC 3.75 respectively.
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In an anomalous right coronary artery arisen from left coronary cusp intervention, Judkins left 4.0 guiding catheter via right radial artery approach can be used.  Adjunct use of microcatheter can be attempted to provide support for catheter engagement into coronary artery.