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Stenting of An Anomalous Left Circumflex Coronary Artery

STEVEN KELLEY, M.D.,* DONALD STEELY, M.D.,? and J. DAVID TALLEY, M.D.$

From the *Division of Cardiology, University of Arkansas for Medial Sciences, Little Rock, Arkansas, fConway Heart Clinic, Conway, Arkansas, and $Cardiology Associates of Paducah, Paducah, Kentucky

Coronary artery anomalies are found in approxi- mately 1 % of the general population. ’ The most com- mon anomaly is the left circumflex artery arising from a separate ostium from the right sinus of Valsalva. We recently cared for a patient with this anomaly, illus- trating two critical points. First, it is critical to appre- ciate that this anomaly may cause myocardial is- chemia. Additionally, percutaneous coronary inter- vention of stenoses in these vessels can be technically challenging.

Patient Presentation

A 42-year-old male complained of chest discomfort consistent with myocardial ischemia. Nine months pre- viously, the patient presented with a similar complaint to another cardiologist. At that time, a persantine Car- diolite (DuPont Merck Pharmaceutical Co., Villerica, MA, USA) revealed a reversible defect in the lateral wall. Cardiac catheterization was reportedly “normal.”

At the time of the current presentation, the patient had a stress echocardiogram showing lateral wall-mo- tion hypokinesis. An aortic root injection showed a large circumflex artery arising from the right sinus of Valsalva. Selective angiography of this vessel re- vealed an 80% lesion in the mid-portion (Fig. 1). An 8Fr multipurpose guide catheter was used to success- fully place a 3.5 mm X 20 mm stent (Fig. 2). The pa- tient remains free of symptoms.

Address for reprints: J. David Talky, M.D. F.A.C.C., Clinical Pro- fessor of Internal Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Cardiology Associates of Paducah, 1532 Lone Oak Road, Suite 7, Paducah, KY 42003. Fax: (270) 442- 0 109, e-mail: JDTalle yMD@ gate w ay . net

Technical Aspects of Percutaneous Intervention Involving Anomalous Left

Circumflex Coronary Arteries

Guiding Catheters. The configuration of the ori- fice, angulation, and route of the anomalous artery de- termines stable guiding catheter support. A Judkins right guide is preferred when the anomalous circum- flex arises as a branch of the right coronary artery. In the event that the anomalous circumflex arises from a separate ostium from the right sinus of Valsalva, a va- riety of guide catheters (short tip Judkins right, Am- platz left, Amplatz right and multipurpose) can be used. Secure guiding catheter support is critical to avoid struggling to complete the procedure.*

Guidewires. Careful inspection of the aberrant cir- cumflex is critical to choose the appropriate guidewire. Several techniques have been described. First, in the event of excessive tortuosity of the proxi- mal segment of the vessel that prevents optimal coax- ial alignment of the guiding catheter, an additional support guidewire may ease engagement.3 Second, a novel technique, using two guidewires, may be useful to facilitate guiding catheter engagement and avoid deepseating in the anomalous circumflex coronary artery.4 In this method, one guidewire is placed in the right coronary artery and the other in the circumflex. In the event of a small, excessive tortuous anomalous cir- cumflex, a very flexible and steerable guidewire may be required to cross the target lesion. These circum- stances can also be tackled by placing the balloon in the proximal segment of the vessel and, with this addi- tional support, the guidewire then may be advanced distally.

Vol. 13, No. 3,2000 Journal of Interventional Cardiology 219

KELLEY, ET AL.

Figure 1. Left anterior oblique projection of an angiographically significant lesion in the mid-portion of the anomalous left circumflex coronary artery. A previous diagnosis catheterization failed to reveal this abnormality. A multipurpose guiding catheter was chosen to selectively engage the vessel.

Devices. Standard balloon angioplasty, stents, and rotational atherectomy have all been used successfully in these vessels. Due to the small caliber and tortuous course of these vessels, bulky and rigid devices are clumsy. Lawton and colleagues first reported the use of a stem6 Due to the small caliber of these vessels, ro- tational atherectomy offers the theoretical benefit to protect side branches and lower the rate of r e s t en~s i s .~

References

I . Talky JD. Congenital anomalies of the coronary arteries. In: Hurst JW ed. Current Therapy in Cardiovascular Diseases, 4th edition. Philadelphia: Mosby-Year Book, Inc., 1994, pp. 127-1 29.

Figure 2. After placing a 3.5 mm X 20 mm long stent, the lesion is dramatically improved with minimal residual stenosis. (Left anterior oblique projection.)

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Ilia R. Percutaneous transluminal angioplasty of coronary arter- ies with anomalous origin. Cathet Cardiovasc Diagn 1995;35: 3 W 1 . Lawton J. McGrath J, Jones JS, et al. Treatment of coronary artery disease in an anomalous coronary artery by placement of an intracoronary stent. Cathet Cardiovasc Diag 1997;41:

Das GS, Wysham DG. Double wire technique for addition- al guiding catheter support in anomalous left circumflex coro- nary artery angioplasty. Cathet Cardiovasc Diag 1991;24: 102-104. Topaz 0, DiSciascio G, Goudreau E, et al. Coronary angio- plasty of anomalous coronary arteries: Notes on technical as- pects. Cathet Cardiovasc Diag 1990;21:106-1 1 1 . Lawton J , McGrath J, Jones JS, et al. Treatment of coronary artery disease in an anomalous coronary artery by placement of an intracoronary stent. Cathet Cardiovasc Diagn 1997;41: 1XS-IX8. Bass TA, Gilmore PS. Ceithaml EL. Rotational atherectomy in anomalous coronary arteries. Cathet Cardiovasc Diagn 1992;27:322-324.

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