Successful Coronary Intervention for Chronic Total Occlusion in an Anomalous Right Coronary Artery Using the Retrograde Approach

Chronic total occlusions (CTOs) are common and are found in approximately one-third of patients with significant coronary disease who undergo angiography.¹ Previous studies have demonstrated the importance of revascularization of CTOs, with improvement in anginal symptoms, exercise capacity, left ventricular function, and long-term survival.^2–5 With the availability of sirolimus-eluting stents (SES) and the dramatic reduction in restenosis rates they provide, CTO lesions have been increasingly treated percutaneously.⁶ According to the literature, coronary anomalies affect around 1% of the general population.⁷ Angioplasty for anomalous coronary arteries is technically challenging,⁸ especially for chronic total occlusion because of suboptimal guiding catheter support, since all of the guiding catheters are designed for normal coronary anatomy. Recently, several techniques and devices have been introduced to improve the angiographic success rate in the treatment of patients with CTO.^9–12 We describe a combination of new methods using the retrograde wire technique, the anchoring technique and the five-in-six system, which were successfully applied in a patient with CTO of an anomalous right coronary artery (RCA). Case Report. A 66-year-old male presented with unstable angina in November 2001. His coronary risk factors included hypertension, hyperlipidemia, diabetes (oral drug therapy) and remote tobacco use. Coronary angiography revealed a total occlusion in the proximal segment of his RCA with anomalous origin, a severe luminal narrowing (75% diameter stenosis) in the middle segment of the left anterior descending artery (LAD), and a severe luminal narrowing (99% diameter stenosis) in the middle segment of the left circumflex artery (LCx). In November 2001, coronary artery bypass graft (CABG) surgery was performed. During CABG, a right internal mammary artery (RIMA) was placed to the LAD, a left internal mammary artery (LIMA) to the LCx and a gastroepiploic artery to the RCA. Four years later, he developed recurrent symptoms of angina. Angiography revealed a total occlusion of the anomalous RCA with good collateral flow from the LCx (Figures 1 and 2), a stenosis in the LAD, occlusions of the RIMA and the gastroepiploic artery and a patent LIMA graft. In October 2005, he underwent his first stent procedure (Cypher™, 3.0 mm x 33 mm, Cordis Corp., Miami, Florida) for the LAD lesion. Since the patient continued to have CCS III symptoms, angioplasty for the CTO in the RCA with anomalous origin was attempted in April 2006. Given the adverse lesion characteristics associated with low procedural success rates (lesion age > 4 years, angulation, calcification, proximal location, no stump and occlusion at side branch), greater stability and backup support of the guiding catheter were essential to cross the CTO lesion. We considered the traditional antegrade approach to be infeasible due to the suboptimal alignment of the guiding catheter. In such cases, to first attempt the traditional antegrade approach may increase procedural time and radiation exposure with more resources, including contrast medium. Therefore, we employed the retrograde approach first. After 10,000 units of heparin were administered, the left coronary artery was engaged with a 7 Fr EBU 3.5 catheter with side holes via the right femoral artery, and the RCA with a 6 Fr SAL 1.0 catheter via the left femoral artery. With a microcatheter (Finecross, Terumo, Japan), a guidewire (Fielder, Asahi Intecc, Japan) was positioned distal to the RCA lesion through a collateral vessel from the LCx (Figure 3). To overcome poor pushability through the marked tortuosity of the collateral artery, a tapered-tip stiff guidewire designed for CTOs (Conquest Pro, Asahi Intecc) was used with an anchoring technique (Maverick OTW 2.5–20, Boston Scientific, Natick, Massachusetts). After partial success with the retrograde approach, a modified see-saw wire technique (bidirectional; ante- and retrograde wires) was used. After balloon dilatation was performed to connect the distal true lumen with the true lumen proximal to the occluded segment, an antegrade Conquest Pro 12 guidewire reached the distal true lumen. Next, 3 Cypher sirolimus-eluting stents (3.5 mm x 23 mm, 3.0 mm x 33 mm x 2 mm) were implanted using the five-in-six system, yielding a good final result (Figure 4). Discussion. Over the last decade, percutaneous management of coronary artery disease has made remarkable progress. With these advances in perspective, it is often stated that successful recanalization of CTOs represents the “last frontier” of percutaneous coronary intervention (PCI), the most technically challenging lesion subset that interventional cardiologists face with low procedural success rates.^13,14 Recently, several techniques and devices have been introduced to improve angiographic success rates in patients with CTOs. These devices and techniques include tapered-tip guidewires,⁹ intravascular ultrasound-guided guidewires to cross CTOs,¹⁵ the five-in-six system,¹⁰ penetration catheters,¹⁶ the anchoring technique¹⁷ and the retrograde approach.¹² Although the incidence is rare (7 angioplasty for anomalous coronary arteries is technically challenging. Since most guiding catheters are designed for normal coronary anatomy, even selective cannulation is difficult for an anomalous coronary artery. As such, inadequate guiding catheter support is a frequent cause for failure in anomalous coronary artery angioplasty. Moreover, greater stability and backup support from the guiding catheter (improved pushability and control) are required to cross the CTO lesion with a wire or balloon compared to non-CTO lesions. Therefore, PCI for CTO in anomalous coronary arteries represents one of the most technically challenging for interventional cardiologists. In this report, we employed several methods to overcome such difficulties. Since the patient’s left coronary artery was of normal origin, we chose a retrograde approach (LCx to the RCA) first. To cross the small zig-zag collateral vessel, we used a hydrophilic guidewire with a microcatheter. To cross the occluded lesion, the dedicated tapered-tip guidewire and anchoring technique was used to overcome poor support through the long journey of the collateral vessel. For stent implantation, the five-in-six system was useful to improve the stability and backup support of the guiding catheter. In conclusion, to the best of our knowledge, we report the first case in the literature of successful coronary intervention in a totally occluded anomalous RCA originating from the left sinus of Valsalva. A combination of techniques, including the retrograde approach via a collateral vessel, was used. Procedural options such as these should be considered when crossing a total occlusion becomes a serious challenge. Acknowledgment. The authors gratefully acknowledge the excellent assistance of all medical personnel in the catheterization laboratory. The authors thank Heidi N. Bonneau, RN, MS, for her expert review of the manuscript.

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