Author: admin

By Deepak Natarajan

Monday, February 26, 2007, www.tctmd.com

Operator(s):

Deepak Natarajan MD, DM

Affiliation:

Indraprastha Apollo Hospitals,New Delhi

Facility:

Departments of Cardiology
Indraprastha Apollo Hospitals, New Delhi, India

History:

A 66 year old hypertensive lady had undergone stenting of her mid right coronary artery (RCA) in 2001. She was on eltroxin for hypothyroidism and was admitted in the ER this time for chest pain at rest and on exertion for the preceding 2 weeks.

Angiography:

• Normal left anterior descending artery (LAD). 
• Normal right coronary artery (RCA). 
• The left circumflex (LCX) artery was anomalous and was seen to be arising from the right coronary sinus very close to the origin of the RCA and had a tight 75% ostial stenosis. 

Procedure:

The LCX was canalized with a 6Fr AR1 guiding catheter, and a 0.0014″ All Star guidewire was advanced across the LCX lesion.  Direct stenting was done using a Multilink Vision bare metal stent 3x12mm at 16atm.  The patient had been maintained on nitroglycerin infusion throughout the procedure and received a bolus of eptifibatide immediately before stenting.

Conclusion:

TIMI 3 flow was achieved and there was no residual stenosis. 

Comments:

Coronary artery anatomic variations are uncommon and have been seen in approximately 0.6-1.6% of patients undergoing coronary angiography. The aberrant LCX from the RCA or the right coronary sinus is the most common anomaly observed and usually discovered by chance during coronary angiography or at autopsy. It is considered benign as it causes no myocardial compromise. However, it becomes important for the cardiac surgeon in case of aortic valve replacement. In the event of substantial atherosclerosis, the presentation may be as an acute myocardial infarction or unstable angina, as in this case. Percutaneous coronary intervention may be simple and effective in both instances.

Conflict of Interest:

None

By Deepak Natarajan

Monday, August 21, 2006, www.tctmd.com

Operator(s):

Deepak Natarajan MD, DM

Affiliation:

Indraprastha Apollo Hospitals,New Delhi

Facility:

Departments of Cardiology
Indraprastha Apollo Hospitals, New Delhi, India

History:

A 59 year-old man was admitted to our service for unstable angina. He was a known hypertensive and had recently undergone an exercise ECG test which was strongly positive. He was not a diabetic and had stopped smoking a couple of years back. His LDL cholesterol was 150 mg%.

Angiography:

His coronary angiogram revealed a 95% bifurcation stenosis at the origin of the posterior descending artery (PDA) from a dominant circumflex coronary (LCX) artery.  The left anterior descending artery (LAD) and the right coronary (RCA) arteries (non dominant) were normal. 

Procedure:

The left coronary artery was engaged with a 7Fr Voda guiding catheter, and two 0.0014″ floppy guide wires were negotiated across the stenosis into the PDA and LCX arteries respectively. Following predilation with a 2x15mm balloon over both wires, a 3x18mm sirolimus eluting stent was positioned into the PDA while another 3x15mm sirolimus eluting stent was placed into the LCX artery. The PDA stent was placed slightly proximal to the LCX stent .  The LCX stent was first deployed at 14atm; and following a coronary angiographic injection, the wire was removed. Next the PDA stent was deployed at 14atm. The result was satisfactory with no complications.  The floppy wire was renegotiated across the PDA stent struts and a 3x15mm balloon was inflated upto 16atm. Subsequent to this, kissing balloon inflations were performed.  The balloons were inflated upto 12atm. Angiography revealed a significant dissection of the PDA distal to the stent.  This was then predilated with a 2.5x15mm balloon and stented with a 2.75x15mm bare metal stent which was deployed at 16atm. 

Conclusion:

The final angiogram demonstrated TIMI 3 flow and no residual stenosis.  The patient was discharged the next day.

Comments:

Dissection of a coronary artery may develop following crush technique stenting. Although uncommon, it can be managed with deployment of an appropriate sized stent. In this case a bare metal stent was used for the sake of economy.

Conflict of Interest:

None