Cardiovasc Interv and Ther DOI 10.1007/s12928-014-0293-1
CASE REPORT
Main trunk crossover stenting in a patient with left internal thoracic artery—protected single coronary artery Sadayuki Kawashima • Jun Shiraishi • Masayuki Hyogo • Takatomo Shima • Takahisa Sawada • Yoshio Kohno
Received: 4 April 2014 / Accepted: 30 July 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract A 74-year-old man with single coronary artery and history of previous coronary artery bypass graft (CABG) was admitted to our hospital with worsening angina. Because of high risk of redo-CABG, we performed transradial percutaneous coronary intervention against the just proximal left anterior descending coronary artery (LAD) stenosis coexisting with short main trunk, anomalous right coronary artery deriving from the mid LAD and patent left internal thoracic artery-distal LAD graft. Under the guidance of IVUS, we successfully implanted an everolimus-eluting stent from the main trunk ostium to the proximal LAD without complications. Keywords Intravascular ultrasound imaging Percutaneous coronary intervention Drug-eluting stent Computed tomography
Introduction An isolated single coronary artery (SCA) is a rare congenital anomaly with an incidence of 0.02–0.06 % in the general population undergoing coronary angiography (CAG) [1–3]. Since a SCA is defined as an only one coronary artery originating from one of the sinus of Valsalvas and supplying the whole heart, a flow-limiting event at the proximal portion in the SCA tree during interventional procedure is theoretically fatal, and indeed experience of stenting in the main trunk in patients with SCA has been
S. Kawashima J. Shiraishi (&) M. Hyogo T. Shima T. Sawada Y. Kohno Department of Cardiology, Kyoto First Red Cross Hospital, Honmachi, Higashiyama-ku, Kyoto 605-0981, Japan e-mail: [email protected]
extremely limited [4]. We describe our experience with an unusual case of SCA, in which an everolimus-eluting stent (EES) could be successfully implanted from the main trunk ostium to the proximal left anterior descending coronary artery (LAD).
Case report A 74-year-old-male with past smoking, diabetes mellitus, dyslipidemia and hypertension was admitted to our hospital with chest oppression on effort. He had undergone coronary artery bypass graft (CABG) surgery [left internal thoracic artery (LITA)-LAD, aorta–saphenous vein graft (SVG)-diagonal branch] for main trunk ostium stenosis in the presence of SCA 14 years before. The left circumflex coronary artery (LCx) was occluded, but hypoplastic, and grafting to the hypoplastic LCx was not performed. Since the SVG graft was occluded and the flow from the LITA graft to LAD was not adequate 6 months after the CABG, he underwent intraaortic balloon pump (IABP)-supported directional coronary atherectomy in the main trunk lesion. Electrocardiography at admission was normal and subsequent transthoracic echocardiography showed hypokinesis in inferoposterior wall. Adenosine-stress myocardial perfusion scintigraphy with thallium depicted rest–redistribution of the inferoposterior wall perfusion with no apparent hypoperfusion in the distal LAD territory. Coronary angiography revealed a severe stenosis in the proximal LAD with short main trunk, total occlusions in the mid LAD as well as in the mid hypoplastic LCx and a diffuse severe stenosis in the distal segment of the anomalous right coronary artery (RCA) arising from the mid LAD (Fig. 1A, B). The distal segment of the LCx was delineated with flow delay via bridge collateral. The LITA
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Fig. 1 A Anterior–posterior cranial view of coronary angiography. B Right anterior caudal view of coronary angiography. Single coronary artery originates from the left sinus of Valsalva and anomalous RCA (white star) arises from the mid LAD. Hypoplastic left circumflex coronary artery is occluded (white arrowhead). C Left anterior view of the LITA connected to the distal LAD. The graft was patent with moderate stenosis at the anastomosis site (white arrow). D Volume-rendered three-dimensional image of the coronary CT. An anomalous RCA arising from the mid LAD traverses anterior to
pulmonary artery (green color). E–H Slab maximum intensity projection images of the coronary CT (E left anterior caudal view, F magnified left anterior caudal view, G multiplanar reconstruction (MPR) image of short-axis view, H color-coded MPR image corresponding to G). Plaque at the just proximal LAD (E white line) has no sign of low-density plaque (area defined as \50 HU is red color-coded). LITA left internal thoracic artery, RCA right coronary artery, LAD left anterior descending coronary artery, Dx diagonal branch
graft to the distal LAD was patent with moderate stenosis at the anastomosis site (Fig. 1C). Coronary computed tomography (CT) confirmed the diagnosis of SCA arising from the left sinus of Valsalva with the anomalous RCA deriving from the mid LAD and traversing anteriorly to the main pulmonary artery (Fig. 1D). In addition, the coronary CT showed no sign of low-density plaque in the culprit lesion (Fig. 1E–H) and depicted diffuse wall thickness of ascending and descending aorta concomitant with plaque protrusion and plaque ulcer in the descending aorta. Based on the clinical history and on the angiographic and CT scan findings, our heart team, which consisted of interventional cardiologists and cardiovascular surgeons, discussed and concluded that percutaneous coronary intervention (PCI) against the proximal LAD might have low risk of no-reflow/slow flow, while redoCABG might have high risk of systemic embolism and
LITA-LAD graft injury. Thus, we planned to perform transradial PCI without IABP-support against the stenosis in the proximal LAD, using a single crossover stenting through the main trunk ostium to the proximal LAD under on-site CABG surgery backup and the condition of dual antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day). A 4-Fr sheath, a 6-Fr sheath and a 6-Fr long sheath were introduced into his right femoral artery, right femoral vein and left radial artery, respectively, and 7,000 U of unfractionated heparin was administered through the right femoral vein sheath. Using a 6-Fr guiding catheter (mach-1, Q 3.5 SH, Boston Scientific) via left radial artery, a guidewire (Sion blue, Asahi Intecc) was passed through the culprit lesion in the proximal LAD and advanced into the anomalous RCA. After another guidewire (Sion black, Asahi Intecc) crossing across the diagonal branch as a protection
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Main trunk stenting in single coronary artery Fig. 2 A Left anterior caudal view of coronary angiography before PCI. B intravascular ultrasound marks the accurate site of main trunk ostium on coronary angiography (a culprit lesion, b main trunk ostium). C Implantation of an everolimus-eluting stent from the main trunk ostium to the proximal LAD. D Final coronary angiography showed no residual stenosis at the culprit lesion. Ao aorta
wire, subsequent intravascular ultrasound imaging (IVUS) depicted much plaque with heterogeneous echo intensity concomitant with some calcification and deep attenuation at the culprit site (Fig. 2A, Ba). The longitudinal length of the attenuated plaque [180° was approximately 2 mm (2 s of IVUS pullback image 9 1.0 mm/s). After predilation using a balloon catheter (Scoreflex, 3.0/10 mm, OrbusNeich) at 10 atm, an EES (XIENCE Xpedition, 3.5/12 mm, Abbott) was implanted at 16 atm under the guidance of IVUS from the main trunk ostium to the proximal LAD, jailing LCx and diagonal branch (Fig. 2Bb, C). The stent was subsequently postdilated with a balloon catheter (NC TREK, 4.0/8 mm, Abbott) at 16 atm with a good angiographic result (Fig. 2D). Final IVUS showed a complete stent apposition with an optimal placement at the ostial main trunk. Since the final CAG as well as IVUS pulled back through the LAD showed no significant stenosis at the stent-jailed diagonal branch ostium, a kissing balloon technique procedure was not added. The overall interventional procedure lasted 60 min and was completed without any procedure-related complications. Two days after the procedure the patient was discharged and kept free of angina.
Discussion There are many variations of SCA, concerning ostial location, anatomical distribution and course of the transverse trunk [1]. In most of SCA cases, main trunk is very short or absent (separate ostia). According to the Lipton’s classification [1], the present case, in which SCA derived from the left sinus of Valsalva, RCA arose from mid LAD and transverse trunk between LAD and RCA traversed anterior to pulmonary artery, would be categorized in the LII-A group, and reports on this type of transverse trunk are still scant [5, 6]. In addition to atherosclerotic change and vasospasm [7], several mechanisms of myocardial ischemia in SCA patients have been proposed, such as slitlike orifice due to acute angle takeoff of the anomalous vessel [8] and compression of the transverse trunk between the aorta and the pulmonary artery [9]. There are some case reports regarding PCI in SCA patients [5, 10–15]. In majority of SCA cases, anomalous vessels tend to have acute angle takeoff near the SCA ostium, and appropriate selection of guiding catheters significantly affects PCI results. Regarding SCA with
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proximal common trunk disease, only one recent report demonstrated stenting at the main trunk ostium of SCA, in which kissing stent technique with sirolimus-eluting stents was used for anomalous bifurcating vessels (separate ostia) arising from right sinus of Valsalva [4]. Because acute closure due to flow-limiting dissection or thrombus formation in the main trunk of SCA during PCI would rapidly lead to catastrophic hemodynamic compromise, it is reasonable to propose that CABG is a first-line revascularization therapeutic strategy for main trunk disease among SCA patients. In the present case, the proximal LAD, which dominated RCA territory in addition to LAD territory itself, might be equivalent to ‘‘main trunk’’, and in case of PCI-based treatment the stent implanted for the culprit in the nearly ostial LAD should cover up to main trunk ostium. Nevertheless, in addition to his clinical background and coronary tree/aorta characteristics described above, the culprit lesion characteristics themselves, such as focal, proximal but non-ostial, less tortuosity and large-vessel reference, made it suitable for PCI. If severe atherosclerotic changes in the descending aorta were absent, transfemoral approach using a 7- or 8-Fr guiding catheter supported by IABP might also be a suitable PCI strategy in the present case. As to prediction of no-reflow/slow flow, IVUS and coronary CT have recently received greater attention. According to the report from Endo M and colleagues, ultrasound attenuation (defined as IVUS images with backward signal attenuation of C180° behind plaque without dense calcium) with a longitudinal length of C5 mm is an independent predictor of no-reflow phenomenon in patients with ST-segment elevation myocardial infarction [16]. In addition, low-density plaque with lesion length of [4.7 mm on coronary CT has also been reported to be a promising predictor of no-reflow during PCI among patients with acute coronary syndrome and those with stable angina pectoris [17]. According to the coronary CT and IVUS findings, the present case with short-segment plaque in the proximal LAD might therefore have low risk of no-reflow during interventional procedure. This is the first report to describe stenting in the main trunk of a SCA arising from the left sinus of Valsalva.
Conclusion The present case suggests that PCI using a drug-eluting stent under heart-team consensus and on-site CABG surgery backup could be an alternative revascularization therapy of choice among SCA patients with proximal common trunk disease in the condition in which CABG is considered to have more procedure-related risk.
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References 1. Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology. 1979;130:39–47. 2. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990;21:28–40. 3. Desmet W, Vanhaecke J, Vrolix M, Van de Werf F, Piessens J, Willems J, et al. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J. 1992;13:1637–40. 4. Stevens GR, Kini AS, Sharma SK. Intervention of stenosed right coronary artery and anomalous left main coronary artery: single main coronary trunk. J Invasive Cardiol. 2008;20:E71–2. 5. Takano M, Seimiya K, Yokoyama S, Okamatsu K, Ishibashi F, Uemura R, et al. Unique single coronary artery with acute myocardial infarction: observation of the culprit lesion by intravascular ultrasound and coronary angioscopy. Jpn Heart J. 2003;44:271–6. 6. Akcay A, Tuncer C, Batyraliev T, Gokce M, Eryonucu B, Koroglu S, et al. Isolated single coronary artery: a series of 10 cases. Circ J. 2008;72:1254–8. 7. Yamamoto K, Koiwaya Y, Tajimi T, Inou T, Mitsutake A, Orita Y, et al. Coronary arterial spasm in single coronary artery. Circulation. 1981;64:1287–90. 8. Cheitlin MD, De Castro CM, McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva. A not-so-minor congenital anomaly. Circulation. 1974;50:780–7. 9. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol. 2000;35:1493–501. 10. Ho¨lschermann H, Coch M, Erdogan A, Tillmanns H. Images in cardiovascular medicine. Primary stenting of an anomalous left anterior descending coronary artery originating from the proximal right coronary artery in a patient with acute non-ST-elevation myocardial infarction. Circulation. 2004;110:e494–5. 11. Roffi M, Eberli FR, Wyttenbach R, Gallino A. Percutaneous coronary intervention of the left main trunk in congenitally anomalous single coronary artery. J Invasive Cardiol. 2001;13:808–9. 12. Shalganov TN. Percutaneous coronary intervention for acute myocardial infarction in a single coronary artery anomaly. Clin Cardiol. 2009;32:E49–51. 13. Tejada JG, Hernandez F, Sanchez I, Martin-Asenjo R. Stenting of anomalous left main coronary artery arising from the right sinus of Valsalva: a case report. Int J Cardiol. 2007;119:266–7. 14. Raddino R, Pedrinazzi C, Zanini G, Leonzi O, Robba D, Chieppa F, et al. Percutaneous coronary angioplasty in a patient with anomalous single coronary artery arising from the right sinus of Valsalva. Int J Cardiol. 2006;112:e60–2. 15. Gupta MD, Girish MP, Subhendu MS, Tyagi S. Percutaneous coronary intervention of all three coronary arteries originating from single coronary artery arising from the right sinus. Cardiovasc Interv Ther. 2013;28:322–6. 16. Endo M, Hibi K, Shimizu T, Komura N, Kusama I, Otsuka F, et al. Impact of ultrasound attenuation and plaque rupture as detected by intravascular ultrasound on the incidence of noreflow phenomenon after percutaneous coronary intervention in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2010;3:540–9. 17. Harigaya H, Motoyama S, Sarai M, Inoue K, Hara T, Okumura M, et al. Prediction of the no-reflow phenomenon during percutaneous coronary intervention using coronary computed tomography angiography. Heart Vessels. 2011;26:363–9.
CASE REPORT
Main trunk crossover stenting in a patient with left internal thoracic artery—protected single coronary artery Sadayuki Kawashima • Jun Shiraishi • Masayuki Hyogo • Takatomo Shima • Takahisa Sawada • Yoshio Kohno
Received: 4 April 2014 / Accepted: 30 July 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract A 74-year-old man with single coronary artery and history of previous coronary artery bypass graft (CABG) was admitted to our hospital with worsening angina. Because of high risk of redo-CABG, we performed transradial percutaneous coronary intervention against the just proximal left anterior descending coronary artery (LAD) stenosis coexisting with short main trunk, anomalous right coronary artery deriving from the mid LAD and patent left internal thoracic artery-distal LAD graft. Under the guidance of IVUS, we successfully implanted an everolimus-eluting stent from the main trunk ostium to the proximal LAD without complications. Keywords Intravascular ultrasound imaging Percutaneous coronary intervention Drug-eluting stent Computed tomography
Introduction An isolated single coronary artery (SCA) is a rare congenital anomaly with an incidence of 0.02–0.06 % in the general population undergoing coronary angiography (CAG) [1–3]. Since a SCA is defined as an only one coronary artery originating from one of the sinus of Valsalvas and supplying the whole heart, a flow-limiting event at the proximal portion in the SCA tree during interventional procedure is theoretically fatal, and indeed experience of stenting in the main trunk in patients with SCA has been
S. Kawashima J. Shiraishi (&) M. Hyogo T. Shima T. Sawada Y. Kohno Department of Cardiology, Kyoto First Red Cross Hospital, Honmachi, Higashiyama-ku, Kyoto 605-0981, Japan e-mail: [email protected]
extremely limited [4]. We describe our experience with an unusual case of SCA, in which an everolimus-eluting stent (EES) could be successfully implanted from the main trunk ostium to the proximal left anterior descending coronary artery (LAD).
Case report A 74-year-old-male with past smoking, diabetes mellitus, dyslipidemia and hypertension was admitted to our hospital with chest oppression on effort. He had undergone coronary artery bypass graft (CABG) surgery [left internal thoracic artery (LITA)-LAD, aorta–saphenous vein graft (SVG)-diagonal branch] for main trunk ostium stenosis in the presence of SCA 14 years before. The left circumflex coronary artery (LCx) was occluded, but hypoplastic, and grafting to the hypoplastic LCx was not performed. Since the SVG graft was occluded and the flow from the LITA graft to LAD was not adequate 6 months after the CABG, he underwent intraaortic balloon pump (IABP)-supported directional coronary atherectomy in the main trunk lesion. Electrocardiography at admission was normal and subsequent transthoracic echocardiography showed hypokinesis in inferoposterior wall. Adenosine-stress myocardial perfusion scintigraphy with thallium depicted rest–redistribution of the inferoposterior wall perfusion with no apparent hypoperfusion in the distal LAD territory. Coronary angiography revealed a severe stenosis in the proximal LAD with short main trunk, total occlusions in the mid LAD as well as in the mid hypoplastic LCx and a diffuse severe stenosis in the distal segment of the anomalous right coronary artery (RCA) arising from the mid LAD (Fig. 1A, B). The distal segment of the LCx was delineated with flow delay via bridge collateral. The LITA
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Fig. 1 A Anterior–posterior cranial view of coronary angiography. B Right anterior caudal view of coronary angiography. Single coronary artery originates from the left sinus of Valsalva and anomalous RCA (white star) arises from the mid LAD. Hypoplastic left circumflex coronary artery is occluded (white arrowhead). C Left anterior view of the LITA connected to the distal LAD. The graft was patent with moderate stenosis at the anastomosis site (white arrow). D Volume-rendered three-dimensional image of the coronary CT. An anomalous RCA arising from the mid LAD traverses anterior to
pulmonary artery (green color). E–H Slab maximum intensity projection images of the coronary CT (E left anterior caudal view, F magnified left anterior caudal view, G multiplanar reconstruction (MPR) image of short-axis view, H color-coded MPR image corresponding to G). Plaque at the just proximal LAD (E white line) has no sign of low-density plaque (area defined as \50 HU is red color-coded). LITA left internal thoracic artery, RCA right coronary artery, LAD left anterior descending coronary artery, Dx diagonal branch
graft to the distal LAD was patent with moderate stenosis at the anastomosis site (Fig. 1C). Coronary computed tomography (CT) confirmed the diagnosis of SCA arising from the left sinus of Valsalva with the anomalous RCA deriving from the mid LAD and traversing anteriorly to the main pulmonary artery (Fig. 1D). In addition, the coronary CT showed no sign of low-density plaque in the culprit lesion (Fig. 1E–H) and depicted diffuse wall thickness of ascending and descending aorta concomitant with plaque protrusion and plaque ulcer in the descending aorta. Based on the clinical history and on the angiographic and CT scan findings, our heart team, which consisted of interventional cardiologists and cardiovascular surgeons, discussed and concluded that percutaneous coronary intervention (PCI) against the proximal LAD might have low risk of no-reflow/slow flow, while redoCABG might have high risk of systemic embolism and
LITA-LAD graft injury. Thus, we planned to perform transradial PCI without IABP-support against the stenosis in the proximal LAD, using a single crossover stenting through the main trunk ostium to the proximal LAD under on-site CABG surgery backup and the condition of dual antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day). A 4-Fr sheath, a 6-Fr sheath and a 6-Fr long sheath were introduced into his right femoral artery, right femoral vein and left radial artery, respectively, and 7,000 U of unfractionated heparin was administered through the right femoral vein sheath. Using a 6-Fr guiding catheter (mach-1, Q 3.5 SH, Boston Scientific) via left radial artery, a guidewire (Sion blue, Asahi Intecc) was passed through the culprit lesion in the proximal LAD and advanced into the anomalous RCA. After another guidewire (Sion black, Asahi Intecc) crossing across the diagonal branch as a protection
123
Main trunk stenting in single coronary artery Fig. 2 A Left anterior caudal view of coronary angiography before PCI. B intravascular ultrasound marks the accurate site of main trunk ostium on coronary angiography (a culprit lesion, b main trunk ostium). C Implantation of an everolimus-eluting stent from the main trunk ostium to the proximal LAD. D Final coronary angiography showed no residual stenosis at the culprit lesion. Ao aorta
wire, subsequent intravascular ultrasound imaging (IVUS) depicted much plaque with heterogeneous echo intensity concomitant with some calcification and deep attenuation at the culprit site (Fig. 2A, Ba). The longitudinal length of the attenuated plaque [180° was approximately 2 mm (2 s of IVUS pullback image 9 1.0 mm/s). After predilation using a balloon catheter (Scoreflex, 3.0/10 mm, OrbusNeich) at 10 atm, an EES (XIENCE Xpedition, 3.5/12 mm, Abbott) was implanted at 16 atm under the guidance of IVUS from the main trunk ostium to the proximal LAD, jailing LCx and diagonal branch (Fig. 2Bb, C). The stent was subsequently postdilated with a balloon catheter (NC TREK, 4.0/8 mm, Abbott) at 16 atm with a good angiographic result (Fig. 2D). Final IVUS showed a complete stent apposition with an optimal placement at the ostial main trunk. Since the final CAG as well as IVUS pulled back through the LAD showed no significant stenosis at the stent-jailed diagonal branch ostium, a kissing balloon technique procedure was not added. The overall interventional procedure lasted 60 min and was completed without any procedure-related complications. Two days after the procedure the patient was discharged and kept free of angina.
Discussion There are many variations of SCA, concerning ostial location, anatomical distribution and course of the transverse trunk [1]. In most of SCA cases, main trunk is very short or absent (separate ostia). According to the Lipton’s classification [1], the present case, in which SCA derived from the left sinus of Valsalva, RCA arose from mid LAD and transverse trunk between LAD and RCA traversed anterior to pulmonary artery, would be categorized in the LII-A group, and reports on this type of transverse trunk are still scant [5, 6]. In addition to atherosclerotic change and vasospasm [7], several mechanisms of myocardial ischemia in SCA patients have been proposed, such as slitlike orifice due to acute angle takeoff of the anomalous vessel [8] and compression of the transverse trunk between the aorta and the pulmonary artery [9]. There are some case reports regarding PCI in SCA patients [5, 10–15]. In majority of SCA cases, anomalous vessels tend to have acute angle takeoff near the SCA ostium, and appropriate selection of guiding catheters significantly affects PCI results. Regarding SCA with
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proximal common trunk disease, only one recent report demonstrated stenting at the main trunk ostium of SCA, in which kissing stent technique with sirolimus-eluting stents was used for anomalous bifurcating vessels (separate ostia) arising from right sinus of Valsalva [4]. Because acute closure due to flow-limiting dissection or thrombus formation in the main trunk of SCA during PCI would rapidly lead to catastrophic hemodynamic compromise, it is reasonable to propose that CABG is a first-line revascularization therapeutic strategy for main trunk disease among SCA patients. In the present case, the proximal LAD, which dominated RCA territory in addition to LAD territory itself, might be equivalent to ‘‘main trunk’’, and in case of PCI-based treatment the stent implanted for the culprit in the nearly ostial LAD should cover up to main trunk ostium. Nevertheless, in addition to his clinical background and coronary tree/aorta characteristics described above, the culprit lesion characteristics themselves, such as focal, proximal but non-ostial, less tortuosity and large-vessel reference, made it suitable for PCI. If severe atherosclerotic changes in the descending aorta were absent, transfemoral approach using a 7- or 8-Fr guiding catheter supported by IABP might also be a suitable PCI strategy in the present case. As to prediction of no-reflow/slow flow, IVUS and coronary CT have recently received greater attention. According to the report from Endo M and colleagues, ultrasound attenuation (defined as IVUS images with backward signal attenuation of C180° behind plaque without dense calcium) with a longitudinal length of C5 mm is an independent predictor of no-reflow phenomenon in patients with ST-segment elevation myocardial infarction [16]. In addition, low-density plaque with lesion length of [4.7 mm on coronary CT has also been reported to be a promising predictor of no-reflow during PCI among patients with acute coronary syndrome and those with stable angina pectoris [17]. According to the coronary CT and IVUS findings, the present case with short-segment plaque in the proximal LAD might therefore have low risk of no-reflow during interventional procedure. This is the first report to describe stenting in the main trunk of a SCA arising from the left sinus of Valsalva.
Conclusion The present case suggests that PCI using a drug-eluting stent under heart-team consensus and on-site CABG surgery backup could be an alternative revascularization therapy of choice among SCA patients with proximal common trunk disease in the condition in which CABG is considered to have more procedure-related risk.
123
References 1. Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology. 1979;130:39–47. 2. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990;21:28–40. 3. Desmet W, Vanhaecke J, Vrolix M, Van de Werf F, Piessens J, Willems J, et al. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J. 1992;13:1637–40. 4. Stevens GR, Kini AS, Sharma SK. Intervention of stenosed right coronary artery and anomalous left main coronary artery: single main coronary trunk. J Invasive Cardiol. 2008;20:E71–2. 5. Takano M, Seimiya K, Yokoyama S, Okamatsu K, Ishibashi F, Uemura R, et al. Unique single coronary artery with acute myocardial infarction: observation of the culprit lesion by intravascular ultrasound and coronary angioscopy. Jpn Heart J. 2003;44:271–6. 6. Akcay A, Tuncer C, Batyraliev T, Gokce M, Eryonucu B, Koroglu S, et al. Isolated single coronary artery: a series of 10 cases. Circ J. 2008;72:1254–8. 7. Yamamoto K, Koiwaya Y, Tajimi T, Inou T, Mitsutake A, Orita Y, et al. Coronary arterial spasm in single coronary artery. Circulation. 1981;64:1287–90. 8. Cheitlin MD, De Castro CM, McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva. A not-so-minor congenital anomaly. Circulation. 1974;50:780–7. 9. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol. 2000;35:1493–501. 10. Ho¨lschermann H, Coch M, Erdogan A, Tillmanns H. Images in cardiovascular medicine. Primary stenting of an anomalous left anterior descending coronary artery originating from the proximal right coronary artery in a patient with acute non-ST-elevation myocardial infarction. Circulation. 2004;110:e494–5. 11. Roffi M, Eberli FR, Wyttenbach R, Gallino A. Percutaneous coronary intervention of the left main trunk in congenitally anomalous single coronary artery. J Invasive Cardiol. 2001;13:808–9. 12. Shalganov TN. Percutaneous coronary intervention for acute myocardial infarction in a single coronary artery anomaly. Clin Cardiol. 2009;32:E49–51. 13. Tejada JG, Hernandez F, Sanchez I, Martin-Asenjo R. Stenting of anomalous left main coronary artery arising from the right sinus of Valsalva: a case report. Int J Cardiol. 2007;119:266–7. 14. Raddino R, Pedrinazzi C, Zanini G, Leonzi O, Robba D, Chieppa F, et al. Percutaneous coronary angioplasty in a patient with anomalous single coronary artery arising from the right sinus of Valsalva. Int J Cardiol. 2006;112:e60–2. 15. Gupta MD, Girish MP, Subhendu MS, Tyagi S. Percutaneous coronary intervention of all three coronary arteries originating from single coronary artery arising from the right sinus. Cardiovasc Interv Ther. 2013;28:322–6. 16. Endo M, Hibi K, Shimizu T, Komura N, Kusama I, Otsuka F, et al. Impact of ultrasound attenuation and plaque rupture as detected by intravascular ultrasound on the incidence of noreflow phenomenon after percutaneous coronary intervention in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2010;3:540–9. 17. Harigaya H, Motoyama S, Sarai M, Inoue K, Hara T, Okumura M, et al. Prediction of the no-reflow phenomenon during percutaneous coronary intervention using coronary computed tomography angiography. Heart Vessels. 2011;26:363–9.
