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CASE20191019_001
| CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS) | |
| Challenging Percutaneous Coronary Intervention Because of Anomalous Right Coronary Artery Origin | |
| Benjamin Leo Cheang Leng1, Tee Choon Keong2 | |
| Columbia Asia Hospital Tebrau, Malaysia1, Sultanah Aminah Hospital, Malaysia2, | |
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[Clinical Information]
- Patient initials or identifier number:
MJS
-Relevant clinical history and physical exam:
59 year old Malay male. He has diabetes, hypertension, chronic kidney disease and a strong familyhistory of ischaemic heart disease. He had chest pain on 7/11/2018, 6am. Went to a district hospital and ECG done revealed Inferior myocardial infarction.Given IV Streptokinase at 9am but there was no resolution of ST segment on ECG and he was in shock. He was transferred to our tertiary center for further intervention.
-Relevant test results prior to catheterization:
Creatinine 195 umol/L. Potassium 5.1 mmol/L. Killip IV. BP 116/75 mmHg on single inotrope,, intravenous Noradrenaline infusion. SaO2 98% on nasal prong oxygen 3 litres. ECHO revealed Global poor LVEF 20-25%, Normal chamber size. No pericardial effusion.
 TCTAP DIAG LAD RAO CAU.avi TCTAP DIAG AP CRA.avi- Relevant catheterization findings:
Mid Left main stem 40 % stenosis, Proximal Left anterior descending artery 30-40% lesion. Cimcumflex artery occluded proximally. Dominant RCA has anomalous origin from left coronary cusp. Proximal occluded. (culprit lesion). Managed to wire the RCA but poor support did not allow a balloon bigger than 1.2 to cross the lesion. TIMI II flow achieved. Procedure stopped in view of contrast use of 150 ml. Procedure time 2 hr 46 min. Patient was staged for repeat attempt to PCI RCA.
TCTAP 1 diag LAO RCA occluded.avi TCTAP 1 final RCA LAO.avi |
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[Interventional Management]
- Procedural step:
On the second attempt, femoral approach used. XB 3.0 guide (same guide that was used in prior attempt) Wiredeasily (Sion black) but could not pass a balloon (1.0 x 10 ) across the lesion.
TCTAP RCA DIAG LAO.avi TCTAP RCA REENGAGED 3 15 BALLOON.avi TCTAP RCA FINAL LAO.avi- Case Summary:
Anomalous origin of RCA poses unique challenges for intervention. In this case , cannulation the RCA was very difficult and the catheter could not provide goodsupport for intervention. The use of a guidezilla would help provide additionalsupport but in this case, it was difficult to cannulate the RCA even with the guidezilla.There were no suitable branches to use for anchor balloon technique. In the end, lots of patience and perseverance was used to successfully treat the pRCA lesion. Patient was discharged well with a plan for myocardial perfusion scan to evaluate LCA lesion. Creatinine 194 umol/L pre and 174 umol/L post procedure.
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