Percutaneous coronary intervention of anomalous left circumflex coronary artery - A case series.

We report a case series of 14 cases (mean age 54.14 ± 14.75 years) of successful percutaneous coronary intervention of anomalous left circumflex artery. While the intermediate-term follow-up (mean 36.0 ± 20.58 months) was uneventful in 12 patients, one died of a non-cardiac cause, while other lost to follow-up.

Anomalous origin of the left circumflex artery (ALCx) from the right sinus is the commonest congenital coronary anomaly. Percutaneous coronary intervention (PCI) of ALCx is technically challenging because of difficulty in selective cannulation and lack of coaxial engagement.

We retrospective reviewed 14 patients (mean age 54.14 ± 14.75 years) of ALCx PCI over the last 7-years. The origin of ALCx was divided into 3 types: Type I (n = 6) is separate ostial origin of right coronary artery (RCA) and ALCx, type II (n = 5) is common ostial origin, and type III (n = 3) is when ALCx arises from the proximal RCA. A Judkins Right (JR) (n = 11) or Amplatz Right-1 (AR-1) (n = 3) coronary guide catheters were used during PCI. One patient required a change of guide catheter from JR to AR1, as the earlier one was not able to cannulate the ALCx. Initial wiring of RCA (two-wire strategy; n = 9) helped in anchoring and stabilizing the guide catheter in right coronary sinus so that another wire with curved tip could cross the non-cannulated ALCx. It also helped in precise placement of ostial ALCx stent and to bailout from any significant plaque/carina shift to RCA. Two angiographic views - LAO 40° with cranial 20° and caudal 20° could clearly delineate the ostium of both RCA and ALCx for selective wiring of the later one. The target lesion was of type B and type C in 50% cases, each. The site of the lesion was ostial in 3 (Fig. 1A and F), proximal/retro-aortic in 5 (Fig. 1B, G, 1E, 1J), distal LCx in 5 (Fig. 1C and H) and obtuse marginal in 1 patient (Fig. 1D and I). Eight patients underwent PCI via femoral access and 6 via radial access. A total of 16 stents (15- drug-eluting stents, 1-bare metal stent) were deployed with a mean stent diameter of 2.95 ± 0.33 mm and a length of 26.93 ± 7.92 mm. The average fluoroscopy time was 13.05 min. One patient died of non-cardiac cause at 5-year follow-up and another lost to follow-up after 3-months of intervention. The remaining 12 patients were asymptomatic at mean follow-up 36.0 ± 20.58 months.

Fig. 1

Coronary angiograms showing baseline (upper row) and post-percutaneous coronary intervention (PCI) images (Lower row) of anomalous left circumflex (ALCx) arising from right coronary sinus. A and F: PCI (F) of type III ALCx having an ostial stenotic lesion (A). B and G: PCI (G) of type II ALCx having a stenotic lesion at retro-aortic segment (B). C and H: PCI (H) of type I ALCx having a stenotic lesion at the distal LCx segment (C). D and I: PCI (I) of type I ALCx having a stenotic lesion of obtuse marginal (D). E and J: PCI (J) of type II ALCx type having thrombotic occlusion, in a case of single coronary (E). All 3 arteries are arising from the right coronary sinus (E).

Out of the 8100 angiograms performed over the last 7-years, 37 (0.45%) patients had ALCx from the right sinus. Of these, 16 patients had normal coronaries, while 21 (56.7%) had significant obstructive coronary artery disease (CAD). Fourteen cases underwent PCI of ALCx, 5 had coronary bypass surgery for three-vessel disease, and 2 cases had PCI of left anterior descending with normal non-obstructive ALCx.

The angiographic prevalence of ALCx is similar to the existing literature. Contrary to some studies,, we did not find ALCx predisposition to atherosclerosis. Although JR or AR-1 guide catheters are frequently used, Amplatz Left and Multipurpose catheters have also been used during PCI. A two-wire strategy is helpful in guide anchoring/stabilization and also prevent ostial RCA injury. Although femoral access (n = 8) could provide good support for various catheter exchange across ALCx, double-wire technique with radial access can be equally effective. The published literature about ALCx PCI is limited to case reports and a few case series of 12 cases by West NE et al and 11 cases by Morgan et al. Although PCI of ALCx is challenging, appropriate angiographic views, use of correct hardware, and operator skills could provide a high procedural success rate and favorable clinical outcomes.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

All authors have none to declare.