Direct-Coronary-Stenting Through the Radial
Approach in an Anomalous Coronary Artery

Tejas M Patel, Sanjay C Shah, Alok Ranjan, Anoop K Gupta

Department of Cardiology, Krishna Heart Institute, Ahmedabad

An anomalous origin of the coronary artery is an infrequent finding on coronary angiogram. Percutaneous coronary intervention may sometimes be difficult in such situations. We report two cases of anomalous coronary arteries in whom direct stenting was done via the radial approach. (Indian Heart J 2002; 54: 422–424)

Key Words: Percutaneous coronary intervention, Coronary artery anomalies, Radial artery

Selective cannulation of anomalous coronary arteries is often difficult; in such vessels angioplasty presents a technical challenge.1 The left Judkin and left Amplatz catheters are the best guiding catheters for an anomalous right coronary artery (RCA) arising from the left coronary sinus.2–4 However, new guiding catheters such as Voda catheters and hockey stick-shaped guiding catheters are also useful in these situations.5 Published case reports have described poor guide support and procedural failure of attempted angioplasty of lesions in anomalous RCAs from the femoral approach.6

The left circumflex artery is very difficult to cannulate selectively if it arises from the first part of the RCA, hence angioplasty in such vessels is often performed by cannulating the RCA. We report two cases of direct stenting in anomalous coronary arteries performed through the radial approach.

Case Report

Case 1: A 48-year-old man with chronic stable angina was referred to our center for a coronary work-up. His stress test was positive at the second stage of exercise. He was subjected to a coronary angiography (CAG) via the right radial artery as per our protocol. The left coronary system was normal and the RCA was difficult to cannulate selectively with routine right Judkin and right Amplatz diagnostic catheters.

An aortogram revealed anomalous origin of the RCA from the left coronary cusp, which was subsequently cannulated with a 5 F JL 3.5 Judkin diagnostic catheter.

Selective angiogram of the RCA revealed a 90% type C lesion in the mid-RCA (Fig. 1A). In view of his symptoms and high-grade lesion, the patient was subjected to coronary intervention during the same sitting. A 5 F sheath was exchanged with a 6 F Terumo sheath (Radio focus, Introducer II; Terumo Corporation, Tokyo, Japan).

The RCA was selectively cannulated with a 6 F FL 3.0 guiding catheter (Boston Scientific Scimed, Inc; MN, USA) and the lesion was crossed with the help of a 0.014" BMW guidewire (Guidant, Advanced Cardiovascular Systems, Inc; CA, USA). Although the morphology of the lesion was unfavorable, a direct stenting of the lesion was planned as per our institution’s protocol. 

A 3.5×24 mm Express stent (Boston Scientific Scimed, Inc; MN, USA) was placed across the lesion in the mid-RCA (Fig. 1B) and the stent was deployed at a pressure of 16 atm (Fig. 1C). There was no residual lesion and the vessel distal to it showed TIMI 3 flow (Fig. 1D). The patient tolerated the procedure well and was discharged the day after the procedure.

Case 2: A 53-year-old man was referred to our center for percutaneous-coronary intervention. He had recently suffered an inferior wall myocardial infarction. His coronary angiogram performed at the referral center showed total occlusion of the RCA in its middle part and an 80% lesion in the proximal circumflex artery, whose origin was from the first part of the RCA (Fig. 2A). The patient was scheduled for planned percutaneous-coronary intervention.

The right radial artery was cannulated and a 6 F Terumo sheath (Radio focus, Introducer II; Terumo Corporation, Tokyo, Japan) was placed inside the radial artery. The cocktail regimen was used to prevent local spasm. The RCA was cannulated with a 6 F 4.0 JR guiding catheter (Boston  Scientific Scimed, Inc; MN, USA) and selective angiogra-phy pictures were recorded. 

The RCA lesion was crossed with the help of a 0.014" Miracle 4.5 PTCA guidewire (Asahi Neo’s, Asahi Intecc Co. Ltd; Aichi, Japan) and the lesion dilated with a 2.5×15 mm cross sail balloon (Guidant, Guidant Corporation; CA, USA). A 4.0×16 mm Express stent (Boston Scientific Scimed, Inc; MN, USA) was deployed at a pressure of 16 atm in view of the 30% re-sidual lesion.

The angioplasty guidewire was not removed from the RCA and a second guidewire 0.014" Choice PT floppy (Boston Scientific Corporation; FL, USA) was used for the lesion in the circumflex artery. (Fig. 2B). The lesion was crossed with some manipulation and the wire was parked in the distal part of the circumflex artery. Direct stenting was planned as per our institution’s protocol. The lesion was stented with a 2.5×10 mm Heli Stent (Hexacath, France) at 14 atm pressure (Fig. 2C). There was no residual lesion following stent deployment (Fig. 2D) and there was brisk flow in the distal part of the vessel. The patient tolerated the procedure well without any complication. He was discharged from the hospital within 24 hours of admission.

Discussion

The incidence of anomalous origin of the coronary arteries is 1%–2% of all patients.7–8 Nevertheless, a busy interventionalist comes across such cases frequently, which can be both challenging and time-consuming. A small-loop left Judkin catheter is most frequently used for an anoma-lous RCA arising from the left coronary sinus.9 However, sometimes it is very difficult to provide adequate guiding support through the femoral approach, especially when deep intubation is required to negotiate complex lesions.

Approach via the right radial artery provides a different guiding catheter angle relative to the coronary sinuses than that achieved via the femoral approach.10 This appears to be advantageous for successful catheterization of aberrant RCAs. The choice of guiding catheter remains the same for the radial approach as that for the femoral route. In the first case, the aberrant RCA was cannulated with a 6 F FL 3.0 guiding catheter and direct stenting of the complex lesion was performed.

In our experience, we found that the right radial approach is better than the femoral approach for intervention of an aberrant RCA. First, the shallow angle of the innominate artery as it arises from the aorta provides a more direct approach for selective cannulation of RCAs arising from the left sinus of Valsalva in comparison to catheters passed around the aortic arch via the femoral approach. Second, selective deep intubation of the guiding catheter in anomalous origin of the RCA is better through the right radial approach. However, it would be very difficult to prove this with a randomized trial, as such anomalies are rare.

Percutaneous transluminal coronary angioplasty in an anomalous left circumflex coronary artery with severe stenosis can be technically challenging, as cannulating the anomalous vessel with the guiding catheter can be difficult. Advancement of stent delivery systems in such cases re-quires good support with the possibility of selective cannu-lation and deep engagement of the guiding catheter.

In the second case, the anomalous vessel originated from the first portion of the RCA. In such a case the right Judkin catheter, with a posteriorly directed tip, is the most appropriate catheter.11 The right Judkin catheter was used in our case too. We found that selective cannulation and guiding support for the anomalous LCx was better via the right radial approach. In addition, we used the double-wire technique for additional guiding catheter support to negotiate the circumflex lesion.12

To the best of our knowledge these are the first few cases of direct stenting of anomalous coronary arteries via the radial route in India.

Correspondence: 
Dr Anoop K Gupta, 
Consultant Cardiologist and Electrophysiologist, 
Krishna Heart Institute, Ghuma, 
Ahmedabad 380058.
e-mail: anoopgupta@msn.com

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