Scientific letter
Successful transradial antegrade recanalization of a chronic total occlusion of an anomalous circumflex artery arising from the right sinus of Valsalva
Revascularización anterógrada exitosa mediante acceso radial de una oclusión total crónica en una arteria circunfleja con origen anómalo en el seno derecho de Valsalva
Javier Benezet
, Antonio Agarrado, Jesús Oneto
Corresponding author
javbenezet@hotmail.com
Corresponding author at: Servicio de Cardiología, Hospital de Jerez de la Frontera, Circunvalación s/n, 11407 Jerez de la Frontera, Cádiz, Spain.
Corresponding author at: Servicio de Cardiología, Hospital de Jerez de la Frontera, Circunvalación s/n, 11407 Jerez de la Frontera, Cádiz, Spain.
Department of Cardiology, Hospital de Jerez de la Frontera, Jerez de la Frontera, Cádiz, Spain
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Vista mediastinoscópica (1<span class="elsevierStyleHsp" style=""></span>d) en donde se aprecian las perlas de sulfato de calcio con antibióticos para liberación prolongada <span class="elsevierStyleItalic">in situ</span>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis Raúl Meza-López, José Angel Cigarroa-López, Silvia Hernández-Meneses, David Arturo Castán-Flores, Genaro Hiram Mendoza-Zavala, José Antonio Barragán-Zamora, Arturo Carrillo-Muñoz, Daniel Alejandro Munguía-Canales" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Luis Raúl" "apellidos" => "Meza-López" ] 1 => array:2 [ "nombre" => "José Angel" "apellidos" => "Cigarroa-López" ] 2 => array:2 [ "nombre" => "Silvia" "apellidos" => "Hernández-Meneses" ] 3 => array:2 [ "nombre" => "David Arturo" "apellidos" => "Castán-Flores" ] 4 => array:2 [ "nombre" => "Genaro Hiram" "apellidos" => "Mendoza-Zavala" ] 5 => array:2 [ "nombre" => "José Antonio" "apellidos" => "Barragán-Zamora" ] 6 => array:2 [ "nombre" => "Arturo" "apellidos" => "Carrillo-Muñoz" ] 7 => array:2 [ "nombre" => "Daniel Alejandro" "apellidos" => "Munguía-Canales" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S140599401730006X?idApp=UINPBA00004N" "url" => "/14059940/0000008700000002/v1_201705190116/S140599401730006X/v1_201705190116/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1405994016300301" "issn" => "14059940" "doi" => "10.1016/j.acmx.2016.04.009" "estado" => "S300" "fechaPublicacion" => "2017-04-01" "aid" => "275" "copyright" => "Instituto Nacional de Cardiología Ignacio Chávez" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Arch Cardiol Mex. 2017;87:178-80" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1738 "formatos" => array:3 [ "EPUB" => 39 "HTML" => 1230 "PDF" => 469 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Anomalía de Ebstein y síndrome de QT largo congénito. A propósito de un caso" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "178" "paginaFinal" => "180" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Ebstein anomaly and congenital long QT syndrome. Report of a case" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2070 "Ancho" => 3000 "Tamanyo" => 891567 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electrocardiograma de 12 derivaciones en reposo, donde se observa ritmo sinusal con incremento de voltaje en la onda «P» sugestivo de crecimiento de la aurícula derecha. En derivaciones precordiales puede apreciarse un bloqueo incompleto de la rama derecha del haz de His, con eje del QRS en el plano frontal de +120°. El segmento ST se observa plano y con onda T acuminada con base amplia. El intervalo PR prolongado con 220<span class="elsevierStyleHsp" style=""></span>ms sugiere bloqueo AV de primer grado. 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The arrow indicates the anomalous origin of a chronically occluded left circumflex artery. (C) Percutaneous coronary intervention with the chronic total occlusion successfully crossed. (D) Synergy<span class="elsevierStyleSup">®</span> stent implanted.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary congenital anomalies of the coronary arteries are rather rare with an incidence of 0.3–1.6%.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Anomalous origin of the left circumflex (LCX) coronary artery from the right sinus of Valsalva is the most common congenital coronary variant, with prevalence at coronary angiography of 0.18–0.67%.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,3</span></a> Percutaneous coronary intervention (PCI) for an anomalous coronary artery is a technically challenging and complicated procedure. We report a very unusual case of an anomalous origin of a chronically occluded LCX artery arising directly from the right sinus of Valsalva that was successfully performed by transradial (TR) antegrade approach.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old female with a past medical history of hypertension presented with an 8-month history of exertional chest pain. An echocardiogram showed normal heart wall movement with normal left ventricular ejection fraction. She exercised for 8<span class="elsevierStyleHsp" style=""></span>min on the standard Bruce protocol and experienced chest pain, and was found to have a 2-mm ST-segment depression in the inferolateral leads at the end of exercise. After obtaining an informed consent, coronary angiography revealed absence of the left main coronary artery, accompanied with the left anterior descending coronary artery without significant obstructive atherosclerotic lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and an anomalous origin of a proximal chronically occluded LCX artery from right sinus of Valsalva with a retro-aortic course with the right coronary artery (RCA) and the LCX sharing a common ostium (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). It was a tapered chronic total occlusion (CTO) in the proximal portion of the anomalous LCX with bending >45 degrees detected within the CTO segment and >20<span class="elsevierStyleHsp" style=""></span>mm occlusion length (JCTO score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The CTO revascularization was performed from the right radial artery. Before the procedure, the patient was taking clopidogrel (75<span class="elsevierStyleHsp" style=""></span>mg/day) and aspirin (100<span class="elsevierStyleHsp" style=""></span>mg/day) and during the procedure, received anticoagulation with unfractionated heparin (70<span class="elsevierStyleHsp" style=""></span>UI/kg) to achieve an activated clotting time of 250–300<span class="elsevierStyleHsp" style=""></span>s. With a 6 Fr Amplatz right (AR) 1 guiding catheter we made a double-wire antegrade technique, involving placement of a separate Sion<span class="elsevierStyleSup">®</span> wire (Asahi Intecc, Japan) into the RCA to anchor the guide, followed by wiring of the anomalous LCX with a Pilot<span class="elsevierStyleSup">®</span> 150 wire (Abbott Vascular, Santa Clara, CA, USA) supported by a 1.0<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm Falcon<span class="elsevierStyleSup">®</span> CTO balloon (Invatec, Roncadelle, Italy). Next, we proceeded with the parallel wire technique with the use of a Pilot<span class="elsevierStyleSup">®</span> 200 wire. This wire punctured the proximal cap at a different position and was easily advanced to the distal true lumen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). The occlusion was predilated with a 2.0<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm Emerge<span class="elsevierStyleSup">®</span> semi-compliant balloon (Boston Scientific, Natick, MA,USA) restoring coronary blood flow. Finally, a 2.75<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>38<span class="elsevierStyleHsp" style=""></span>mm Synergy<span class="elsevierStyleSup">®</span> (Boston Scientific, Natick, MA, USA) bioabsorbable polymer drug-eluting stent was deployed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D) with a good angiographic result (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A), which was confirmed by optical coherence tomography (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B) and coronary computed tomography angiogram study after angioplasty (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">To the best of our knowledge this is the first case presented of successful recanalization of a CTO in an anomalously arising LCX performed by TR antegrade approach. Anomalies of the origin and course of the LCX coronary artery are amongst the most frequently encountered. The anomalous LCX originates from the right coronary cusp, either directly, or as a branch from the RCA and courses behind the aorta to the left part of the atrioventricular sulcus, where it resumes its usual configuration. This anomaly is classified as benign since it is not known to predispose individuals to sudden cardiac death. However, some studies have proposed a higher incidence of atherosclerosis and myocardial infarction in the presence of this anomaly.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Anomalies of the LCX artery pose several potential challenges to the interventional cardiologist. Selection of the appropriate equipment (guiding catheter/wire) assumes greater importance, ranging from successfully engaging the ostium of the anomalous coronary artery with adequate support to advance interventional devices and ultimately, concluding the procedure with minimal exposure to contrast agents and radiation. PCI on anomalous LCX vessels is technically feasible, with a high procedural success rate when performed by experienced operators.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> CTOs successful recanalization in patients with viable myocardium has been shown to reduce symptoms like angina decrease the need for surgery and improve survival.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> According to the standard practice of the majority of CTO-dedicated centers and operators, PCI on CTO are attempted using large guiding catheters and trans-femoral approach. The TR approach is a valuable alternative to trans-femoral approach, which has been shown to reduce vascular complications and possibly be associated to a better clinical outcome.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Anomalous coronary arteries are rare and clinically significant. PCI for an anomalous coronary artery is a technically challenging and complicated procedure. We would like to emphasize the feasibility of a TR approach even for complex lesions such as the one in this patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interests regarding the publication of this paper.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1280 "Ancho" => 1500 "Tamanyo" => 264933 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A, B) Baseline coronary angiography. The arrow indicates the anomalous origin of a chronically occluded left circumflex artery. (C) Percutaneous coronary intervention with the chronic total occlusion successfully crossed. (D) Synergy<span class="elsevierStyleSup">®</span> stent implanted.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 685 "Ancho" => 1900 "Tamanyo" => 194581 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Final angiographic result. (B) Optical coherence tomography image showing good stent apposition. (C) Coronary computed tomography angiogram after angioplasty.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary anomalies: incidence, pathophysiology, and clinical relevance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Angelini" 1 => "J.A. Velasco" 2 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 16 | 1 | 17 |
| 2024 September | 18 | 4 | 22 |
| 2024 August | 12 | 2 | 14 |
| 2024 July | 14 | 4 | 18 |
| 2024 June | 12 | 2 | 14 |
| 2024 May | 5 | 1 | 6 |
| 2024 April | 24 | 3 | 27 |
| 2024 March | 32 | 9 | 41 |
| 2024 February | 33 | 4 | 37 |
| 2024 January | 30 | 3 | 33 |
| 2023 December | 35 | 6 | 41 |
| 2023 November | 23 | 7 | 30 |
| 2023 October | 34 | 6 | 40 |
| 2023 September | 15 | 5 | 20 |
| 2023 August | 26 | 3 | 29 |
| 2023 July | 25 | 3 | 28 |
| 2023 June | 25 | 7 | 32 |
| 2023 May | 28 | 6 | 34 |
| 2023 April | 26 | 7 | 33 |
| 2023 March | 36 | 6 | 42 |
| 2023 February | 26 | 5 | 31 |
| 2023 January | 32 | 2 | 34 |
| 2022 December | 35 | 3 | 38 |
| 2022 November | 29 | 10 | 39 |
| 2022 October | 33 | 6 | 39 |
| 2022 September | 23 | 6 | 29 |
| 2022 August | 40 | 7 | 47 |
| 2022 July | 30 | 11 | 41 |
| 2022 June | 22 | 5 | 27 |
| 2022 May | 21 | 5 | 26 |
| 2022 April | 23 | 5 | 28 |
| 2022 March | 45 | 6 | 51 |
| 2022 February | 27 | 22 | 49 |
| 2022 January | 21 | 13 | 34 |
| 2021 December | 30 | 7 | 37 |
| 2021 November | 44 | 9 | 53 |
| 2021 October | 45 | 6 | 51 |
| 2021 September | 38 | 10 | 48 |
| 2021 August | 28 | 10 | 38 |
| 2021 July | 21 | 6 | 27 |
| 2021 June | 17 | 6 | 23 |
| 2021 May | 36 | 5 | 41 |
| 2021 April | 45 | 11 | 56 |
| 2021 March | 53 | 7 | 60 |
| 2021 February | 33 | 4 | 37 |
| 2021 January | 37 | 8 | 45 |
| 2020 December | 45 | 9 | 54 |
| 2020 November | 36 | 5 | 41 |
| 2020 October | 29 | 5 | 34 |
| 2020 September | 30 | 8 | 38 |
| 2020 August | 38 | 7 | 45 |
| 2020 July | 18 | 10 | 28 |
| 2020 June | 17 | 9 | 26 |
| 2020 May | 25 | 4 | 29 |
| 2020 April | 15 | 7 | 22 |
| 2020 March | 24 | 4 | 28 |
| 2020 February | 20 | 2 | 22 |
| 2020 January | 16 | 6 | 22 |
| 2019 December | 35 | 8 | 43 |
| 2019 November | 12 | 2 | 14 |
| 2019 October | 16 | 1 | 17 |
| 2019 September | 33 | 8 | 41 |
| 2019 August | 16 | 3 | 19 |
| 2019 July | 25 | 14 | 39 |
| 2019 June | 28 | 26 | 54 |
| 2019 May | 73 | 28 | 101 |
| 2019 April | 29 | 5 | 34 |
| 2019 March | 6 | 4 | 10 |
| 2019 February | 9 | 5 | 14 |
| 2019 January | 2 | 1 | 3 |
| 2018 December | 5 | 2 | 7 |
| 2018 November | 11 | 2 | 13 |
| 2018 October | 11 | 3 | 14 |
| 2018 September | 5 | 6 | 11 |
| 2018 August | 7 | 4 | 11 |
| 2018 July | 10 | 1 | 11 |
| 2018 June | 6 | 0 | 6 |
| 2018 May | 12 | 5 | 17 |
| 2018 April | 5 | 0 | 5 |
| 2018 March | 7 | 0 | 7 |
| 2018 February | 6 | 1 | 7 |
| 2018 January | 12 | 1 | 13 |
| 2017 December | 10 | 2 | 12 |
| 2017 November | 12 | 1 | 13 |
| 2017 October | 12 | 1 | 13 |
| 2017 September | 19 | 4 | 23 |
| 2017 August | 18 | 2 | 20 |
| 2017 July | 24 | 4 | 28 |
| 2017 June | 32 | 13 | 45 |
| 2017 May | 20 | 8 | 28 |
| 2017 April | 2 | 2 | 4 |
| 2017 March | 5 | 36 | 41 |
| 2017 February | 1 | 3 | 4 |
| 2016 December | 3 | 5 | 8 |
| 2016 November | 11 | 11 | 22 |
| 2016 October | 8 | 8 | 16 |
| 2016 September | 5 | 4 | 9 |
| 2016 August | 10 | 5 | 15 |
| 2016 July | 0 | 1 | 1 |
Show all