Trans-radial Angioplasty of Anomalous Origin of Right Coronary Artery: A Single-Centre Experience

Successful percutaneous coronary intervention (PCI) to anomalous coronary arteries is technically challenging, particularly through transradial route. The application of appropriate techniques and devices may help overcome these challenges. The objective of this study is to explore the technical and procedural challenges in percutaneous coronary intervention (PCI) of anomalous origin of right coronary artery (AORCA) through the trans-radial route. This prospective study consisted of 25 consecutive patients who underwent PCI for an angiographically significant stenosis in AORCA from November 2017 to May 2019 at Ibrahim Cardiac Hospital & Research Institute (ICHRI). Demographic details and procedural data including numbers of catheters used, access, hardware, techniques, duration of procedure, volume of contrast and complications were recorded and statistically analyzed. The origin of AORCA was 48.0% each from the right and left coronary sinus, with 4.0% arising from the ascending aorta. Among those of right coronary sinus origin, superior take off was 83.3% and inferior take-off was 8.3%, with a further 8.3% originating from the left main, with a common origin with the left anterior descending (LAD) artery, from right coronary sinus. The mean age was 55.8±7.5 years. Diabetics were 84.0%, hypertensive 88.0%, dyslipidemic 68.0% and 20.0% had a history of smoking. Percutaneous coronary intervention (PCI) was performed successfully in 100.0% cases. Transradial access was the default route for coronary angiography in all cases. Angioplasty was performed trans-radially in 92.0% and trans-femoral in 8.0%, for two cases requiring switch over from radial to femoral route. The average number of guide catheters used was (2.0±1.0), (range: 1-4). The guide catheter hooked the coronary ostium selectively in 32.0%, off ostium in 56.0% and deep intubation was done in 12.0% cases. Anchoring wire to enhance guide support was used in 12.0%. 6 Fr guide extension catheter Guidezilla was used in 8.0% cases. The average duration of the procedure was 39.4 (range; 15-90) minutes, the average volume of contrast used was 67.0 (range: 30-150) ml. Average stent length was 28.6 (range; 12-43) mm. For PCI, Judkin's left (JL) and Judkin's Right (JR) were most commonly used guides (36.0% and 28.0% respectively), followed by multipurpose angled (MPA) guide (12.0%). The majority of the lesions stented were of ACC/AHA classification of type B (48.0%) followed by type A (36.0%) and type C (16.0%). Thrombus extraction was performed in a single case. One case was complicated by coronary artery dissection. PCI of AORCA through transradial route is technically challenging but feasible with a reasonable amount of contrast and radiation, and appropriate use of guides and techniques. Proper localization of ostium and selection of suitable guide is the key to success, aided by additional devices in the armamentarium of interventional cardiology such as guide extension catheter and anchoring wires.