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Interventions in Anamalous Coronary Arteries

Tips in doing Interventions in Anamalous Coronary Arteries

Dr. DB Pahlajani

Senior Cardiologist

Breach Candy, Mumbai



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Dr.DB Pahlajani

Very nice case has been presented so far, very challenging, and I must say all the young guys have done a tremendous job and got success in all the cases that they presented. What I am going to be going to talking to you is just to give you few tips on tackling a patient who suspected to have an anomalous coronary artery. First of all, I have not kept the cases in the particular order, they are at random and as the cases keep on coming, I will just keep on talking how one should tackle those cases. First of all, coronary artery anomaly global incidence is 5.64% and sudden death incidence is 0.6%. (100) Anomalies are classified not only in the anatomic morphology and the origin but it is also described in its course termination and its main important is physiologic hemodynamics. Most of them are benign as somebody pointed out amongst the presenters but some of these cases can have a very malignant course especially what case was presented with a single anomalous coronary artery, single coronary artery or a left circumflex going between the aorta and the pulmonary artery where sudden death has been reported. Now the most important thing about the anomalies of the coronary arteries is not how you tackle it as a matter of fact. The most important is when to suspect an anomaly of the coronary artery.(200) We are doing an angiogram, you do not know you have gone inside and you expect that the left coronary artery will be arising from the left sinus and the right will be arising from the right sinus, you take the left Judkins, you take the right Judkins and you feel everything is going to be hunky-dory. Then suddenly you find that you are not able to cannulate and that is the time if you take time more than what you usually take to finish a coronary angiogram, please suspect an anomalous coronary artery because that is the first thing that you have got to learn. The reason is many of our patients have got a renal dysfunction, so when you keep on hunting for the coronary artery, you inject contrast, some of these patients have gotten an acute coronary syndrome, some of these patients like what was presented to have got an acute myocardial infarction and you have taken the patient (300)for PAMI with the time is of great essence and you are talking about the door-to-balloon time of 90 minutes, so you keep the index of suspicion very high in case you find that you have taken longer time than the usual. Then once you have realized by injecting the cuspal shots because the way to find out where to suspect, where the coronary artery is located and if you cannot cannulate by the conventional method, do cuspal injections and by the cuspal injections then you must know where it is arising from and the very important thing is choose the appropriate hardware,. Appropriate hardware means to the appropriate guiding catheter, wires, and the balloons to see that your guide catheter or your diagnostic catheter is engaged co-axially. Most of them are as I said benign but some of them can be malignant. Very important I think (400)is probably not realized the best way to diagnose an anomalous coronary artery is on the CT angio. When you cannot cannulate an artery, you cannot seat on the cuspal injection, you should abandon the procedure. If it is not an acute situation, send the patient for CT angio and you will be able to localize the origin of the anomalous coronary artery where it is coming from for example, here is a patient who has gotten right coronary artery arising from the left cusp and is coursing in front of the aorta. For example, you can see this is a patient who had an acute inferior wall infarction came in the middle of the night and we took the patient for primary angioplasty and found that left coronary system was normal and right coronary artery (500)we could not localize. So did a cuspal injection, saw the right coronary artery coming out from the left sinus and in such a situation we usually first thing that we take is the 3.5 left Judkins catheter. Go to the left sinus, make a loop and take the loop back towards upwards or downwards below the origin of the left coronary artery and inject there. If the left Judkins does not go take a left Amplatz catheter and try to negotiate there and that is what you see in the first thing. Then the next thing that we do is if you cannot get into the ostium deep we keep on doing the probing through the wire, get through a wire down and then over the wire put in a balloon, small balloon 1-5-mm or 2-mm balloon then guide the guide catheter or the diagnostic catheter into the coronary artery (600)so that the catheter sits co-axially (at least the last one is running, thank God). This is how we completed with the left Amplatz catheter, you can see we positioned it through the wire over the small balloon went down into the right coronary artery put the Amplatz catheter little co-axially and then went down, put in a balloon and then the stent and got a good result on the right coronary artery. Similarly, here is a patient with a left main disease with a right coronary artery. Left main coronary angioplasty was done and then we kept on exploring the right coronary artery which was coming out from the left sinus, took in an Amplatz and kept on exploring the left sinus and by rotating it clockwise came down into (700) the right coronary artery and you can see there is a tight lesion which was tackled by putting in a stent there and the catheter is sitting co-axially. I think for us the right coronary artery coming from the left sinus the choice is either the left Judkins, small catheter 3.5 or putting the Amplatz catheter and what about the circumflex, we saw some of the cases where the circumflex was coming out from the right coronary artery and can see here very innocuous looking angiogram, you see the left main, LAD and the artery just below the LAD and many times you did a casual angiogram you will feel that this is a circumflex (800) but be sure that this is not a circumflex whether this is early diagonal which is arising, so when you go to the right coronary artery, you see the right coronary artery and you are happy that the right coronary artery is diffusely diseased and the circumflex is normally arising from the left coronary artery but when you see a small right coronary artery like this more or less like a non-dominant right coronary artery suspect that you are missing something on the left side because the posterior part and the lateral wall has got to be supplied with some vessel, so may be I think we have missed the circumflex and you keep on exploring the right sinus and there you see that the circumflex is coming out from the right sinus. So many times you see as the (900)diagonal branches which are very large coming from out from the LAD, you mistake them for circumflex and then when you see a small right coronary artery like this suspect that there may be a circumflex which is coming out from the right sinus. Similarly, another case where you find an LAD which has got a tight lesion and a very large diagonal is coming out and here still you should suspect that the circumflex is anomalous because when you see such a long left main in patients who have got an anomalous circumflex coming out from the right usually they got a long left main like this. So if you see a long left main like this always suspect that there may be an anomalous circumflex and this is how it was in this particular patient. (10



  • Heart Attack
  • MI
  • ECG
  • Hypertension
  • BypassSurgery
  • Stent

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