PMC6079552_01
Coronary computed tomography revealing that the RCA originates from the left coronary sinus and passes between two great vessels. Ao = aorta, PA = pulmonary artery, and RCA = right coronary artery.
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Coronary computed tomography indicated that the RCA originated from the left coronary sinus and passed between the aorta and the pulmonary artery (Figure 1).
Atherosclerotic findings of the RCA lesion. Spotty calcification and mild positive remodeling were noted. Ao = aorta, PA = pulmonary artery, and RCA = right coronary artery.
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The RCA lesion had atherosclerotic findings such as spotty calcification and mild positive remodeling (Figure 2).
Coronary angiography revealing tight stenosis at the LAD-D1 bifurcation. AP = anterior-posterior projection, CRA = cranial angulation, D1 = first diagonal branch, L = lateral projection, and LAD = left anterior descending artery.
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The abnormal RCA had multiple collaterals from the LAD and left circumflex branch (Figures 3 and 4).
Coronary angiography revealing a completely occluded right coronary artery originating from the left coronary sinus. The abnormal right coronary artery had multiple collaterals from the left anterior descending artery and left circumflex branch. AP = anterior-posterior projection, CAU = caudal angulation, LAO = left anterior oblique view, and RAO = right anterior oblique view.
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The abnormal RCA had multiple collaterals from the LAD and left circumflex branch (Figures 3 and 4).
Cannulation of the guiding catheter to the anomalous orifice of the RCA. Cannulation was difficult, and it was not possible to achieve adequate backup support. A 7-Fr Amplatz Left II Mach 1 coronary catheter was used. LAO = left anterior oblique view, LCA = left coronary artery, and RCA = right coronary artery.
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Ultimaster 3.0 x 18 mm (Terumo Corporation); and intravascular ultrasound (IVUS) catheter, 40 MHz rotational OptiCross (Boston Scientific). Cannulating the guiding catheter to the anomalous orifice of the RCA was difficult, and it was not possible to achieve adequate backup support (Figure 5). Using the XT-R guide wire, the Mizuki microcatheter could not be passed though the chronic total occlusion lesion until it was replaced with a Caravel microcatheter.
Passing the guide wire and microcatheter through the lesion. When using the XT-R guide wire, only the Caravel and not the Mizuki microcatheter could be passed though the lesion. The anchor balloon technique was used to create extra support for the guiding catheter. The wire was then exchanged to Sion blue.
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The wire was then changed to Sion blue (Figure 6).
Intravascular ultrasound revealing diffuse eccentric calcified plaque, and the intramural course of the proximal ectopic artery was elliptical with some lateral compression.
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However, the stenosis of the proximal intramural course was not so severe that we did not deploy the stent in the proximal portion (Figure 7).
Stenting strategy. After preballooning with Ikazuchi 1.0 x 10 mm and Tazuna 2.0 x 15 mm, angioplasty with a drug-eluting stent (Ultimaster 3.0 x 18 mm) was performed, followed ballooning with Raiden 3.5 x 10 mm.
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Multiple ballooning and angioplasty with a drug-eluting stent were performed (Figure 8), and an optimal result was obtained (Figure 9).
Final coronary angiography (CAG). Optimal results were noted. LAO = left anterior oblique view and RAO = right anterior oblique view.
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Multiple ballooning and angioplasty with a drug-eluting stent were performed (Figure 8), and an optimal result was obtained (Figure 9).
Percutaneous coronary intervention (PCI) for revascularization of the left anterior descending artery. After preballooning with Tazuna 2.0 x 15 mm, angioplasty with a drug-eluting stent was performed (Ultimaster 3.0 x 10 mm), followed by ballooning with Raiden 3.5 x 10 mm.
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At the same time, PCI was performed for LAD revascularization, and an optimal result was obtained (Figure 10).