MSNK

60 year old man, with background history of hypertension and dyslipidemia. He had NSTEMI in 2018, ECHO showed good EF of 56%. Coronary angiogram showed 2VD, with severe stenosis proximal LAD and CTO proximal RCA (anomalous origin from left SOV). As patient refused surgery, PCI to LAD was done, however, it was a failed attempt of PCI to CTO RCA. After 4 years, patient had worsening angina and ischemic study confirmed presence of large ischemia at RCA territory.

Gamma Nuclear Cardiology:There is a large area of stress induced ischemia in the LCX/RCA territory.The global left ventricular function is good.
Transthoracic Echo:EF 60%. TAPSE 1.9 cm. Mild aortic regurgitation. Normal left ventricular size.
CT Cardiac:Anomalous origin of the ostial of the RCA from the border of the LCC and RCC with inter-arterial route. The ostial of the RCA has slit-like appearance. There is calcified plaque causing total occlusion at the proximal and mid RCA.

Left Main Stem : SmoothLeft Anterior Descending : Patent Left Anterior Descending stent, collaterals to Right Coronary ArteryLeft Circumflex Artery : Mild disease distallyRight Coronary Artery : Anomalous origin from left sinus of Valsalva, just slightly inferior and medial to origin of left main stem. Chronic Total Occlusion proximal Right Coronary Artery

An attempt by intervention team 4 years ago was unsuccessful in view of failed selective engagement despite on 4 different catheters (JR 4, EBU 3.5, AL 0.75, AL 1.5). We’re comfortable with radial approach & unconventionally opted for JR 3.5 specifically to avoid injury to slit-like ostium & nearby left main. Engagement was difficult as JR kept on hugging the aortic wall. It was later made possible with “No-Touch” technique with gap created by Teflon, and wired successfully from outside. No backup force was expected from catheter throughout procedure. With Fielder XT as workhorse wire & Fielder FC in AV node branch for support, CTO was successfully crossed. We were unable to pass Caravel down despite additional soft wire at SA node branch for extra support. Microcatheter was escalated to Turnpike LP and with the aid of balloon anchor (2.0mm) at SA node branch, microcatheter was sent down in rotational movement. Sequential pre-dilatation& delivery of 1^st stent (3.0/35mm) were done with balloon anchor support. In view of possible ischemia to SA node (intermittent junctional bradycardia), balloon anchor was omitted & soft wire was used as buddy wire for delivery of 2^nd stent. However, it was not successful. Hence, 2^nd stent (3.5/38mm) was also delivered via balloon anchor strategy. Balloon anchor was then removed and as a wire with best shaft support, Grand Slam was used as buddy wire for delivery of post-dilatation balloon.

This describes a rare case of CTO proximal anomalous RCA, arises from left SOV, just slightly inferior and medial to the left main. The ostial is slit-like with inferior take-off, hence poses additional technical challenge. This is only the 5^th reported case of successful intervention of CTO of anomalous RCA from left SOV, with antegrade wire escalation strategy. Tough catheter engagement was overcome with meticulous & skillful catheter manipulation. Improvisation of variety of techniques for hardware delivery ensure procedural success. Equally essential, adjacent left main which was left unharmed was the icing on the cake.