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Guideliner vascular solutions1/3/2024 These include atherosclerosis frequently present at the proximal points of branching, Usually benign, anomalous RCA from LAD may occasionally cause ischemia by various mechanisms. In most cases, the origin of the anomalous RCA is from the proximal to mid‐portion of the LAD. In a review of literature reported 36 published cases describing this type of anomaly. In a series of 126 595 coronary angiograms reported by Yanmanaka et al, Patient made uneventful recovery and was discharged two days after procedure.Ī single coronary artery arising from the left coronary sinus, with the right coronary artery arising from the left anterior descending artery, is an extremely rare coronary artery anomaly. A satisfactory angiography result with Thrombolysis in myocardial infarction (TIMI) 3 flow in both LAD and RCA was seen with no residual stenosis and no dissection (Figure 8). ![]() Proximal optimization was done with a 3.5 × 12 mm Voyager NC balloon (Abbott Vascular) at 20 atmospheric pressure. Final kissing balloon postdilatation of this bifurcation at mid‐LAD and RCA was done with two noncompliant balloons, Voyager NC 3 × 15 mm (Abbott Vascular) in mid‐LAD and Voyager NC 2.75 × 15 mm (Abbott Vascular) in RCA (Figure 7). Serial dilatation of ostium of RCA was done first with 1.5 × 8 mm, 2.0 × 10 mm, and finally with 2.5 × 10 mm Sprinter balloon (Medtronic Inc Figure 6). Use of a 6F GuideLiner catheter close to the origin of RCA ostium facilitated the negotiation of the balloon to the ostial RCA. Fielder XT wire (Asahi Intecc) was used to recross RCA stent. A 3 × 23 mm Xience Xpedition stent (Abbott Vascular) was placed in mid‐LAD and deployed at 12 atmospheric pressure (Figure 5). This stent was then crushed with a 2.75 × 18 mm Sprinter balloon (Medtronic Inc Figure 4). It was positioned in proximal RCA with slight protrusion into the LAD and deployed at 12 atmospheric pressure (Figure 3). ![]() A Xience Xpedition 2.75 × 15 mm stent (Abbott Vascular) was negotiated into the anomalous RCA using the 6F GuideLiner catheter. The LAD lesion was predilated using a 2.5 × 15 mm Sprinter balloon (Medtronic Inc). A 2.5 × 15 mm Sprinter balloon (Medtronic Inc) was advanced into the anomalous RCA and predilatation of ostial anomalous RCA was done at 14 atmospheric pressure (Figure 2). Negotiating a balloon into the anomalous RCA was little challenging because of a sharp angle, necessitating the use of a 6F GuideLiner catheter (Vascular Solutions). The RCA lesion was then crossed with another 0.14 inch BMW universal wire (Abbott Vascular) and parked in the posterior descending artery. A 0.14 inch Balance middleweight (BMW) universal wire (Abbott Vascular) was used to cross the LAD lesion and was positioned in distal LAD. The left main artery was engaged with an XB3 7F (Cordis) guiding catheter. Procedure was done through right femoral route using 7F sheath. Preprocedural clearance and bleeding risk stratification from the gastroenterologist was taken in view of Hepatocellular carcinoma (HCC). ![]() In view of symptomatic disease with a large area of myocardium at risk and a life expectancy of >1 year, a decision to revascularize was taken. ![]() Left coronary angiogram showing a heavily calcific LAD with ostio‐proximal patent LAD stent and diffuse 70%‐80% stenosis in mid‐LAD, a dominant RCA with anomalous origin from mid‐LAD and ostial 90% stenosis (Medina 1,1,1 disease at the mid‐LAD and anomalous RCA bifurcation) The Left anterior descending artery (LAD)/Right coronary artery (RCA) bifurcation lesion was successfully treated using the mini‐crush technique. We describe a complex and rare percutaneous intervention to the left anterior descending and right coronary artery bifurcation in a 77‐year‐old patient with anomalous origin of the right coronary artery from mid‐left anterior descending artery and Medina 1,1,1 disease at the bifurcation. Use of nonstandard hardware may be required for adequate access and support. Percutaneous intervention in anomalous coronary arteries is particularly challenging. Usually benign, it may result in ischemia by various mechanisms including atherosclerotic involvement of the vessels, rendering a critical area of myocardium at risk. To the best of our knowledge, this is the third such intervention reported in world literature and the first from India.Ī single coronary artery arising from the left coronary sinus, with the right coronary artery arising from the left anterior descending artery, is an extremely rare coronary artery anomaly. The LAD/RCA bifurcation lesion was successfully treated using the mini‐crush technique. We report a rare percutaneous intervention to the left anterior descending (LAD) and right coronary artery (RCA) bifurcation in a 77‐year‐old male patient with anomalous origin of the right coronary artery from mid‐left anterior descending artery and Medina 1,1,1 disease at the bifurcation.
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