Percutaneous intervention of chronic total occlusion of anomalous right coronary artery originating from left sinus - Use of mother and child technique using guideliner.

Anomalous origin of right coronary artery (RCA) from left sinus is a rare clinical entity. Percutaneous coronary intervention of such an anomalous RCA, which is chronically occluded, is difficult and is rarely described. We describe such an intervention in a patient, who had a chronic total occlusion of anomalous RCA and discuss the technical issues associated with such interventions.

A 49-year-old female presented to us with exertional chest pain and breathlessness for 3 months. She had an unsuccessful attempt of percutaneous intervention chronic total occlusion of anomalous right coronary artery (RCA). RCA originated anomalously from the left sinus but near the midline and above the origin of the left coronary artery (Fig. 1a). Our prior experience made us to select a short JL guide (JL3, Cordis, USA) to guide the intervention. A 0.014 wire Fielder wire (Terumo Corporation) was used to get the support so as to engage the guide in a better position. Later a 6F Guideliner (Vascular Solutions, USA) was used to selectively engage the right coronary artery (Fig. 1b) utilizing anchored balloon technique, where a 2 mm short balloon (Minitrek, Abbott Vascular) was inflated proximal to the CTO to track the guideliner distally. With this mother and child technique (JL3 catheter and guideliner), using different CTO hardwares like Miracle 6 bros wire (Asahi, Abbott Global), a pilot 150 (Abbott Vascular, US) and Confianza Pro9 (Abbott Vascular, US), distal cap of the CTO was penetrated to reach distal true lumen (Fig. 2a). After gradual dilatation of the lesion with s balloons (1.25 and 1.5 balloons), 2/20 mm (Maverick2 balloon), it was stented with two 2.75/38 mm Promus element stents with good end result (Fig. 2b). Though guideliner has been used to revascularize anomalous RCA originating from left sinus, usage of guideliner to revascularize chronic total occlusion of ARAOS has never been described before. In summary, a proper planning of PCI of ARAOS including identifying the lesion, selection of appropriate guide and upfront use of selection of special devices like guideliner will make the procedure easy, safe, and successful.

Fig. 1

(a) Right coronary injection in left anterior oblique view showing the relation of origin of right and left coronary artery from left sinus. It also shows the chronic total occlusion of mid RCA. (b) Guideliner was placed through a fielder wire with the support of an uninflated balloon kept in the proximal right coronary artery for better support.

Fig. 2

(a) Lesion was crossed with Confianza Pro-9 wire with the support of guideliner. (b) Final result of procedure with TIMI III flow.

Conflicts of interest

The authors have none to declare.