PTCA of Total Occlusion of Anomalous RCA using

Modified AL 2 catheter

Dr P Uday Prashant MD DM MD, DM

Consultant CardiologistPOULAMI HOSPITALS

Hyderabad

Introduction• Isolated coronary anomalies occur 1% in general

population and incidence of RCA anomalies is 0.09%

• Medline search revealed only 4 isolated case reports on PTCA of chronic total occlusion of anomalous RCA

• “ to the best of our knowledge, we report the first case in the literature of successful coronary intervention in a totally occluded anomalous RCA originating from the left sinus of Valsalva” - Hideaki Kaneda, MD, PhD, Saeko Takahashi, MD- Jan 2007; Journal of Invasive Cardiology

Case History• 34 yr old male smoker, alcoholic• History of severe chest pain 3-4 mo back not

properly treated.• Since then complaining of chronic stable angina• ECG shows e/o old Inferior wall MI.

• CAG on 1/9/2010 showed anomalous RCA origin near left Sinus of valsalva with 100% cut off & retrograde filling from left system

CAG

• By radial route did left system CAG• But when encountered difficulty in RCA

cannulation changed to femoral• Multiple unsuccessful attempts to cannulate

with JR, RR, AR catheters • AL 2 6F catheter successful in cannulating RCA.• Procedure time took 2 hours with 250-300 ml

dye contrast.

FIRST ATTEMPT• Taken up for elective PTCA after 3 days of hydration.• Kept on LMW heparin after CAG.• AR1 guiding catheter engaged successfully whereas

AL 1 or AL 2 failed during first attempt.• AL catheters couldn’t engage because the ostium of

anomalous RCA is directed inferiorly instead of superior direction

• But AR catheter couldn't give enough support and again due to prolonged procedure time and dye constraint procedure abandoned

Newer techniques for anomalous RCA total occlusions

• Deeper engagement guiding catheters,• Tapered-tip guidewires - 0.009 cm tip• Intravascular USG guided guide wires• The five-in-six system or mother and child

technique - insertion of flexible tip cathter• Penetration catheters- TORNUS, microcatheter • The anchoring technique17 and • The retrograde approach

• Ikari et al quantitatively measured the backup force of guiding catheters for the right coronary artery.

• Three factors were found to be associated with the backup force: catheter size, angle (theta) of the catheter on the reverse side of the aorta and the area of contact made by the catheter on aorta4. • The angle (theta) determines the force that can dislode the

guiding catheter.

In my case I felt if we could have proper guiding catheter it would solve all the problems instead of resorting to complicated techniques

Successful PTCA

• On 9/9/2010 patient was again taken for repeat attempt of PTCA stent to RCA.

• Realized only AL catheter would give enough support for successful PTCA even if other catheters could cannulate RCA.

• But simple AL `s Primary curve not suitable to intubate RCA and secondary not enough to provide sufficient support

• So decided to shape catheter after taking aortic root measurements

• The catheter was shaped outside gently by making distal curve or primary curve straight so that it is more co-axial to RCA ostium.

• The secondary curve is made very wide and elongated so that it sits in Antero posterior diameter of root of aorta and the opposite aortic wall provides backup force during intervention

• Whisper wire used initially but was going into false lumen with lot of resistance.

• So exchanged with BMW wire along with 1.5 * 10 mm Sprinter balloon support and after lot of difficulty crossed the CTO

Analysis of 24 pts among 40,000 CAG`s with Anomalous RCA PTCA

• Type A was found in four patients; that is above the left Sino-tubular plane. For three of them Forward Takeoff Judkins (FL) catheter successfully used and one patient required Femoral Curved Left (FCL).

• Type B was in five patients; this is below the origin of LCA. In four cases among five, FCL3.0 or 3.5 was successful.

• Type C was common and it was in nine patients; in which RCA originating from between the LCA and the midline. At this originating point Voda Left (VL) was successful in eight cases out of nine.

• Type D was in just six cases, where anomalous RCA originating in or from the midline of first and third lines. In this type of anomalous RCAs; Amplatz Left 1 (AL1), Amplatz Left 2 (AL2) and Amplatz Left 3 (AL3) were used in three, one and one patients respectively

Sarkar et al……

• Rahman and others [18] are the first to provide solution for catheter selection based on patient’s image data.

• They consider the RCA curve length and curve angles as well as catheter’s curve length and curve angle and suggest an optimal catheter for the RCA based

on these computations

Optimal catheter selection for anomalous Right Coronary Arteries (RCA) Usman Rauf This thesis is presented as part of Degree of Master of Science in Electrical Engineering Blekinge Institute of technology January 2011Blekinge Institute of Technology, School of Engineering University Supervisor: Dr. Jörgen Nordberg

Conclusions

• PTCA to total occlusion of anomalous RCA is not only technically challenging but also a rare combination. Only 4 case reports

• Many of the difficulties in such situations can be overcome initially by selecting appropriate guiding catheter instead of going for more complicated procedural techniques.

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