IHJ Cardiovascular Case Reports (CVCR) 4 (2020) 4e6

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IHJ Cardiovascular Case Reports (CVCR)

journal homepage: www.elsevier.com/locate/ihjccr

Primary angioplasty in anomalous right coronary artery originating

from mid left anterior descending artery presenting with anterior wall
myocardial infarction
Amar Nath Upadhyay a, *, Barun Kumar b, Manira Dhasmana a
a
Department of cardiology Shri Mahant Indiresh (SMI) Hospital, Kedarpur Village Rd, Industrial Area, Govt.Industrial Estate, Patel Nagar, Dehradun,
Uttarakhand, 248001, India
b
Department of cardiology All India Institute of Medical Sciences, Virbhadra Road Shivaji Nagar, near Barrage, Sturida Colony, Rishikesh, Uttarakhand,
249203, India

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: A subset of anomalous coronary artery patients presenting as acute coronary syndrome are
Received 16 February 2020 invariably hemodynamically unstable. Timely reperfusion with standard door to device time is real
Accepted 13 May 2020 challenge in management of such patients.
Presentation of case: Here, we reported a rare case of a 35-year-old male presenting with ST-elevation
Keywords: myocardial infarction with total thrombotic occlusion of proximal left descending artery (LAD) with
Anomalous coronary artery
anomalous right coronary artery (RCA) originating from mid LAD, distal to the total occlusion.
Anterior wall myocardial infarction
Discussion: Co axial engagement of guiding catheter and delivery of hardware to target lesion are usual
Left descending artery
Right coronary artery
challenges during percutaneous intervention in anomalous coronary artery. However in our case local-
ising the anomalous artery was real challenge.
Conclusion: The traditional concept of” open the occluded artery and see,” can be a logical step in
localizing the anomalous artery.
© 2020 Published by Elsevier B.V. on behalf of Cardiological Society of India. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.1. Introduction 1.2. Case report

The reported prevalence of anomalous coronary artery in pa-
tients undergoing elective coronary angiography is about 1%.1 The
coaxial engagement by guiding catheter and successful hardware
delivery to the target lesion is usually a challenge during percuta-
neous coronary intervention in such patients. A subset of such
patients presenting as acute coronary syndrome are invariably
hemodynamically unstable. Timely reperfusion with standard door
to device time is the treatment goal in such patient. We are
reporting a rare case of ST-elevation myocardial infarction (STEMI)
with total thrombotic occlusion of proximal left descending artery
(LAD) with anomalous right coronary artery (RCA) originating from
mid LAD, distal to the total occlusion.
* Corresponding author. Department of Cardiology, SMI hospital, Dehradun,
India.
E-mail addresses: dramarupadhyay@gmail.com, drbarun79@gmail.com
(A.N. Upadhyay), dhasmanamanira@gmail.com (B. Kumar).
A 35-year-old male nondiabetic, normotensive, smoker pre-
sented with complaints of chest pain since 3 hours. The vital pa-
rameters at presentation were 110/70 mmHg blood pressure, 80
bpm pulse rate, and blood oxygen saturation level (SPo2) 94%. The
electrocardiogram showed ST-segment elevation at v1 to v4, aVR,
and reciprocal changes in v5, v6, II, III, and aVf (Fig. 1). The echo-
cardiogram showed hypokinesia of inferior septum, inferior wall,
anterior septum, and anterior wall with severe left ventricular
systolic dysfunction. The patient was shifted for left heart cathe-
terization after giving loading doses of antiplatelets (aspirin and
clopidogrel), statins, and intravenous heparin. The diagnostic
angiogram showed, normal left main (LM) bifurcating into left
anterior descending (LAD), co-dominant LCX, and proximal total
thrombotic occlusion of LAD (Fig. 2). However, the right coronary
artery (RCA) could not be engaged in the right aortic sinus with a
diagnostic Tiger( terumo) catheter. Only a small artery originating
from the right sinus could be visualized by sinus angiogram (Fig. 3).
The diagnostic catheter was exchanged for a guiding catheter and
the left coronary artery (LCA) was engaged. The LAD was wired

https://doi.org/10.1016/j.ihjccr.2020.05.001
2468-600X/© 2020 Published by Elsevier B.V. on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 A.N. Upadhyay et al. / IHJ Cardiovascular Case Reports (CVCR) 4 (2020) 4e6 5

Fig. 1. Electrocardiogram showing ST-segment elevation and reciprocal changes.

Fig. 2. Left coronary angiogram showing proximal total occlusion of left anterior Fig. 4. Right coronary artery (RCA) originating from mid left anterior descending ar-
descending artery (LAD). tery (LAD).

Fig. 3. Right coronary sinus angiogram.

Fig. 5. Course of right coronary artery (RCA) in right atrioventricular (AV) groove in left
with floppy wire and thrombosuction was done. After a few runs of anterior oblique (LAO) projection.

thrombosuction, the antegrade flow was established in LAD and

angiogram showed RCA originating from mid LAD (Fig. 4). A good
1.3. Discussion
landing zone was noted between LAD lesion and origin of RCA and
drug-eluting stent (DES) was deployed. The TIMI 3 flow became
Clinical significance of anomalous origin of coronary artery
established in distal LAD as well as RCA after stent deployment (see
stems from its propensity to cause myocardial ischemia because of
Fig. 5).
its anatomic origin or course.2 We are reporting a rare case of acute
6 A.N. Upadhyay et al. / IHJ Cardiovascular Case Reports (CVCR) 4 (2020) 4e6
coronary syndrome where the anomalous coronary artery was non-
culprit but myocardial ischemia in its subtended territory resulted
because of its abnormal origin.2
The usual challenges during the intervention in the anomalous
coronary artery are successful engagement and hardware delivery.3
In our case, the most important challenge was to localize the
anomalous artery.
We propose that flow disturbance caused by trifurcation of LAD,
large septal, and RCA could have led to accelerated plaque pro-
gression and eventual rupture in proximal LAD.
Funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None.
Acknowledgements
None.
References
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origin of the right coronary artery from the left anterior descending artery with
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