Stenting of Atherosclerotic Stenoses in Anomalously Arising Coronary Arteries

ABSTRACT: This description of five cases brings to 37 the total number of reported patients in whom atherosclerotic lesions of anomalously arising coronary arteries have been stented. One-half of these have been right coronary arteries arising from the left sinus of Valsalva, followed in frequency by branches of single coronary arteries arising from solitary aortic ostia and left circumflex arteries arising from the right sinus of Valsalva or from the proximal portion of the right coronary artery. Proper guide-catheter selection, essential for successful stenting, usually matches the guide’s configuration to the sinus of Valsalva from which the anomalous artery originates rather than to the final distribution of the coronary artery. J INVAS CARDIOL 2004;16:283–286 Key words: angioplasty, angina pectoris, myocardial infarction, restenosis, thrombosis Coronary arterial anomalies occur in approximately 1% of the population without other congenital cardiac malformations. Some of these anomalies, such as a coronary artery arising from the pulmonary trunk, a coronary arteriovenous fistula, and a coronary artery having a slit-like orifice because it arises from the contralateral coronary sinus, are intrinsically hazardous. Many, if not most, of the numerous coronary arterial anomalies, however, pose no inherent threat to the patient. Nevertheless, these arteries, most of which are abnormal because of an anomalous origin, are probably just as susceptible to atherosclerosis as are normally arising coronary arteries. Despite the widespread use of coronary arterial stenting, surprisingly few reports of managing atherosclerotic stenoses of anomalous coronary arteries with this treatment modality have appeared. We are aware of only 32 such patients in the world literature,^1–18 and only one report contains more than 3 patients.¹⁰ We describe here the use of stents to treat atherosclerotic narrowing of anomalous coronary arteries in 5 symptomatic patients seen over the past 7 years at hospitals affiliated with the Louisiana State University Health Sciences Center in New Orleans. We then review previous studies to tabulate both the anomalies treated and, because guide selection usually is the key to successful stenting, which guiding catheters have been effective for which arteries. Three of our patients (Cases 1–3) are among 5 previously described briefly in abstracts on angioplasty of anomalously arising coronary arteries.¹⁹ Case Studies Case #1. A 42-year-old woman received alteplase for an acute inferior myocardial infarction. Angina pectoris occurred on the third and fourth days after infarction. Angiography revealed complete occlusion in its midportion of a right coronary artery arising from the left sinus of Valsalva (Figure 1). Because the orifice of the anomalous right coronary artery could be engaged with a left Amplatz 1 but not with a right Judkins 4 diagnostic catheter, an 8 French left Amplatz 1 short-tip guiding catheter with side holes (Boston Scientific, Natick, Mass.) was chosen and gave adequate support for dilation of the lesion with a 3.0 x 20 mm Ranger balloon (Boston Scientific, Natick, Mass.) and stenting with a 3.0 x 40 mm Gianturco-Roubin stent (Cook Cardiovascular, Bloomington, Ind.). An intermediate Hi-Torque guidewire (Guidant Corp., Santa Clara, Calif.) was used to deliver the balloon and stent. Aspirin, heparin, abciximab and ticlopidine were given. Angina disappeared, but it recurred 5 months later. A 70% in-stent restenosis was dilated leaving Case #2. A 61-year-old man received retaplase for an acute anterior myocardial infarction. Five days later coronary arteriography showed the left main coronary artery arising just below the orifice of the right coronary artery in the right sinus of Valsalva; the left coronary passed behind the aorta to reach the left ventricle. The left anterior descending coronary artery had an 80–90% stenosis in its proximal portion with a lesser stenosis distally (Figure 2). Dilation of the proximal lesion with a 2.5 mm x 20 mm CrossSail balloon (Guidant Corp., Santa Clara, Calif.), passed through a multipurpose guiding catheter, was followed by placement of a 3.0 mm x 12 mm AVE S670 stent (Medtronic Corp., Minneapolis, Minn.) in the proximal lesion. Because of mild stenosis at the distal end of the 3.0 x 12 mm stent, a 3.0 mm x 9 mm AVE S670 stent (Medtronic Corp., Minneapolis, Minn.) also was deployed. The CrossSail balloon and AVE S670 stents were delivered over a Hi-Torque Balance Middle Weight guidewire (Guidant Corp., Santa Clara, Calif.). The distal lesion was not dilated. He received aspirin, heparin, eptifibatide, and clopidogrel. Seven weeks later the patient had another acute anterior myocardial infarction treated with retaplase. Three days after that, treatment of a 50–60% in-stent restenosis with a 3.0 mm cutting balloon left Case #3. A 57-year-old woman came at the end of three days of stuttering chest pain caused by a small lateral myocardial infarction. Arteriography revealed a single coronary artery arising from the right sinus of Valsalva. The left coronary artery had a retroaortic course and stenoses in the left main, left anterior descending, and left circumflex arteries (Figure 3). Dilation of the left circumflex and of the left main coronary arteries was performed using a 6 French multipurpose guiding catheter and a 2.5 mm x 15 mm CrossSail balloon (Guidant Corp., Santa Clara, Calif.). The left circumflex was then stented with a 2.5 mm x 12 mm AVE S-660 stent (Medtronic Corp., Minneapolis, Minn.), and the left main received a Penta 3mm x 13 mm stent (Guidant Corp., Santa Clara, Calif.). Both stents were delivered over a Hi-Torque Balance Middle Weight guidewire (Guidant Corp., Santa Clara, Calif.). The stenosis in the very small left anterior descending was not dilated. She received aspirin, heparin, eptifibatide, and clopidogrel and had an uneventful post-procedural course. Case #4. A 46-year-old man, with prior stenting of his left anterior descending coronary artery, suffered an acute inferior myocardial infarction and was treated with alteplase and rescue angioplasty. The right coronary artery arose from the left sinus of Valsalva and was totally occluded distally. Angioplasty was performed using an 8 French left Amplatz 1 guiding catheter, 3 mm x 20 mm and 3.5 mm x 20 mm Gemini balloons (Guidant Corp., Santa Clara, Calif.), and 4 mm x 9 mm and 4 mm x 12 mm GFX2 (Medtronic Corp., Minneapolis, Minn.) overlapping stents. The balloons and stents were delivered over a Hi-Torque Floppy guidewire (Guidant Corp., Santa Clara, Calif.). He received nitroglycerin, heparin, abciximab, atropine, and neosynephrine. He has remained free of symptoms during office follow-up of 12 months. Case #5. A 51-year-old man with a history of hypertension, hyperlipidemia, and coronary artery disease presented with increasing exertional chest pain. The left circumflex coronary artery arose from the right sinus of Valsalva and had a 70% stenosis. Angioplasty was performed using a right Amplatz 1 guiding catheter, an All Star guidewire, and a 3.5 mm x 12 mm Express 2 stent (Boston Scientific Corp., Natick, Mass.). He received aspirin, clopidogrel, eptifibatide, enalapril, and atorvastatin. He was discharged the day after the procedure and has remained asymptomatic for 10 weeks. Discussion. Among the 37 patients (including the 5 patients in this report) in whom an anomalously arising coronary artery or one of its branches was stented, the right coronary artery arising from the left sinus of Valsalva was the most common anomaly and occurred in 19 (51%) (Table).^1–18 This anomaly has not been found to constitute such a high proportion of anomalous coronary arteries in any prior study. Origin of the right coronary artery from an orifice more superior and leftward than usual, but still above the right coronary cusp or the commissure between the right and left cusps is a common variant that often is difficult to distinguish from a right coronary arising from the left sinus of Valsalva. Inclusion of this variant as cases of anomalous right coronary artery arising from the left sinus of Valsalva may have skewed the data. Branches of a single coronary artery arising from a solitary aortic ostium (5 from the right sinus of Valsalva, 3 from the left) were stented in 8 patients (Table). The left main coronary artery was stented in 2 patients with a single coronary artery, including our Case #3, who also had her left circumflex stented and who was the only one of the 37 patients to have more than one anomalous artery stented. A far more common anomaly than a single coronary artery is origin of the left circumflex artery from the right sinus of Valsalva or from the proximal portion of the right coronary artery, but stenting of such an anomalous left circumflex or its obtuse marginal branches has been reported only 6 times. Essential to angioplasty and stenting of an anomalous coronary artery is diagnosing the anomaly itself, which is not always easy. For example, a left circumflex arising from the right sinus of Valsalva is one of the most common coronary arterial anomolies. When that artery arises separately from the right sinus, rather than as a branch of the right coronary, injections of the right may not visualize it. Unless the angiographer has recognized the left circumflex as it passes below and behind the aortic root on the right-anterior-oblique left ventriculogram (the so-called “dot sign”), or that what appears to be the left main coronary is too long, or searches in the right sinus with an inferiorly directed catheter tip, e.g., with a right graft or a multipurpose catheter, the diagnosis may be missed. Proper selection of a guiding catheter also is essential to successful angioplasty, with or without stenting, of anomalously arising coronary arteries.²¹ A guiding catheter with the same configuration as the successfully employed diagnostic catheter is a good place to start, but more coaxial support is needed for stenting than for arteriography. A look at the Table is helpful in selecting either a diagnostic catheter or a guiding catheter. With occasional exceptions, the guides used successfully are those matched to the sinus of Valsalva from which the anomalous artery arises rather than to the eventual distribution of the artery. Coronary arteries arising from the left sinus of Valsalva, be they normal or anomalous, are likely to be successfully cannulated with a left Judkins, a left Amplatz, or a left Voda. Like normal arteries arising from the right sinus of Valsalva, anomalous arteries arising there are likely to be catheterized without difficulty using a right Judkins, a right or left Amplatz, or a multipurpose catheter. Although a right Judkins guide has been used successfully in a patient with an anomalous left circumflex arising from the right sinus of Valsalva (Table), because of the inferior take-off of the artery a multipurpose, a right Amplatz, or a right bypass graft catheter might be a better choice. Technical difficulties may arise because of the course of the branch to be stented, but these usually can be overcome with good coaxial guide support. In 2 of our patients restenosis occurred after the initial stenting procedure. Although it is possible that anomalous arteries are more prone to restenosis than normally arising ones, our data, 2 of 5 cases, clearly are insufficient to support such a conclusion, and virtually none of the prior studies have commented on the presence or absence of restenosis.^1–18 In our Case #1, use of a 40 mm Giantarco-Rubin stent may have played a role in restenosis. A 40 mm stent was needed, and the Gianturco-Rubin was the only one available to us. In Case #2, the recent coronary occlusion and the fact that the distal lesion was not dilated initially may have played roles in restenosis. Study limitations. The abnormal origin and course of anomalous coronary arteries could make them more prone to atherosclerosis because of altered flow patterns. Although this has been suggested,¹⁵ and is an important issue, no defensible data are available on whether anomalous coronary arteries are more or less prone to atherosclerosis than normally arising ones. Likewise, although nearly all reports of stenting anomalously arising coronary arteries describe success, failures are unlikely to be reported. Consequently no reliable estimate of the likelihood of success with angioplasty and stenting of such arteries is available.