Aberrant Circumflex Coronary Artery Intervention Using the “Anchoring Wire” Technique

Mzee Ngunga, MD, William Hui, MD, FRCPC, FACC, CK Hui Heart Centre, Royal Alexandra Hospital, Edmonton, Canada
Mzee Ngunga, MD, William Hui, MD, FRCPC, FACC, CK Hui Heart Centre, Royal Alexandra Hospital, Edmonton, Canada

The authors can be contacted via Dr. Mzee Ngunga at mzee.ngunga@aku.eduVideo for this article is available at "Using the 'Anchoring Wire' Technique for Aberrant Circumflex Coronary Artery Intervention."

Abstract

There has been a tremendous surge in the utilization of coronary angiography and angioplasty in recent years. Clinicians will encounter a wide variety of coronary anatomies, including aberrant coronaries. These present a major challenge for both diagnosis and coronary intervention, if required. We present herein a case of successful intervention of sequential lesions in an aberrant circumflex artery arising from the right coronary ostium, using a 5 French guide catheter and an anchoring wire into the normal right coronary artery to enable successful wiring of the aberrant vessel.

Introduction

Coronary artery anomalies are found in 0.6-1.5% of all coronary angiograms.1 The most common anomaly is an aberrant circumflex artery arising from the right sinus of Valsalva [common or separate ostium with the right coronary artery, (RCA)] or directly as a branch of the RCA itself, occurring in approximately 0.48-0.7% of cases.2-5 Co-axial catheter engagement of the anomalous circumflex coronary artery can be difficult, and inadequate visualization of this artery during diagnostic angiography is not uncommon. Furthermore, should the aberrant circumflex coronary artery require coronary intervention, a significant curve on the coronary intervention wire that may be required to access the aberrant circumflex may not be the ideal curve for crossing the culprit lesion. We report a case of successful intervention of two lesions in an anomalous circumflex artery using an anchoring wire in the right coronary artery.

Case report

Figure 1. (Click thumbnail to view larger image.)

A 62-year-old man with hypertension, dyslipidemia, positive family history and a past history of smoking presented with Canadian Cardiovascular Society (CCS) Class II angina and a positive exercise stress test. He underwent coronary angiography via the right radial approach using 5 French (F) diagnostic catheters. This showed a right dominant system and an aberrant circumflex artery that arose from the proximal right coronary artery with a 90% proximal lesion visualized only during dye reflux from injection through the right coronary ostium (Figure 1 and 2, Video 1 and 2). The right coronary and left anterior descending arteries showed diffuse atherosclerotic changes and the lesions were less than 50% diameter stenosis.

Figure 2. (Click thumbnail to view larger image.)

The culprit lesion was determined to be the proximal circumflex lesion, but selective engagement of this artery was difficult despite using Judkins Right (JR) 4, Amplatz Right (AR) 1 and multipurpose guide catheters. An Amplatz Left (AL) 0.75 guide catheter would transiently engage and then disengage from the aberrant vessel during each cardiac cycle.

Figure 3. (Click thumbnail to view larger image.)

At this point, a Runthrough NS wire (Terumo) was used to cross into the distal RCA as an “anchoring wire” for the guide catheter. It was then possible to obtain much more stable co-axial engagement of the circumflex ostium and cross the proximal circumflex lesion with another Runthrough wire (Figure 3, Video 3).

Once the wire in the circumflex was in a secure distal location, the wire in the RCA was withdrawn, since a balloon or stent would not fit into a 5F guide catheter with two wires. The guide catheter was adjusted using wire bias to selectively engage the aberrant circumflex artery.

Figure 4. (Click thumbnail to view larger image.)

The proximal circumflex lesion was then predilated with a 2mm mini-Trek balloon (Abbott), and then stented with a 2.25×28mm Xience V stent (Abbott). The whole circumflex circulation was then well visualized and a 90% lesion was identified in a large obtuse marginal branch (Figure 4, Video 4). 

Figure 5. (Click thumbnail to view larger image.)

It was directly stented with a 2.25×15mm Xience V stent. An excellent final angiographic result was obtained (Figure 5, Video 5). The patient was discharged home the next day without any complications. His troponin I and CK remained negative after the procedure.

Discussion

This case describes use of the “anchoring wire” technique to stabilize guide catheter engagement of an aberrant circumflex ostium sharing the same origin as the RCA. Much as the AL 0.75 guide catheter was not a perfect fit for the aberrant vessel ostium, the anchoring wire prevented disengagement and allowed much better torque control for co-axial catheter engagement for wiring the aberrant circumflex, better visualization and coronary intervention.

Aberrant circumflex coronary arteries seem to have a high incidence of atherosclerosis. In one case series4, all patients with an aberrant circumflex artery and coronary artery disease had significant stenosis of the proximal portion of the anomalous vessel. Intervention of aberrant circumflex coronary arteries is always challenging for interventional cardiologists.6 In the setting of acute myocardial infarction, precious time is often lost because of failure to find a guide catheter that engages the artery well. In one case report of acute myocardial infarction in an aberrant circumflex artery, the operator used a JR 4.5F guide catheter, a catheter size not commonly stocked in most cath labs.7 Finding the “perfect fit” guide catheter for an aberrant circumflex percutaneous coronary intervention has always been challenging for the interventional cardiologist. There are several case reports in the literature where different guide catheters have been used to obtain good support to facilitate angioplasty. In cases where the circumflex arises from a separate ostium in the right sinus of Valsalva, Schwartz et al8 and Topaz et al9 used a JR 4, Kimbiris et al10 used an AL 1, and Bass et al11 used an AR 1 guiding catheter. In cases with the circumflex arising from the RCA ostium, Rivitz et al12 and Topaz et al9 used JR 4 guiding catheters, while Kimbiris et al10 used a modified right Judkins with a heat gun to point the tip of the catheter to the right. However, as in this case, finding the right catheter may be time consuming, and require a significant amount of fluoroscopic radiation and contrast load, which can all be reduced by using an anchor wire in the non-culprit RCA without having to find the "perfect fit" catheter.

The anchoring wire technique can also be applied in left coronary interventions where the guide catheter selectively engages the non-culprit branch. Here, the anchoring wire allows controlled disengagement of the guide catheter and another angioplasty guide wire can then be directed into the culprit branch. Once satisfactory wire position is obtained in the culprit branch, withdrawal of the anchoring wire will often result in selective guide catheter engagement of the culprit branch and allow coronary intervention to proceed smoothly.

Conclusion

The anchoring wire technique is a feasible option for successful intervention of anomalous coronary artery arising from the RCA ostium. Since finding an appropriate guide catheter may not be easy due to angulation of the anomalous vessel, using an anchoring wire in the normal RCA will facilitate wiring of the anomalous vessel, and subsequent delivery of balloon and stents. This technique can be used successfully with a 5F guide catheter.

This article received double-blind peer review from members of the Cath Lab Digest editorial board. The authors can be contacted via Dr. Mzee Ngunga at mzee.ngunga@aku.edu.

References

  1. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990 Sep;21(1):28-40.
  2. Wilkins CE, Betancourt B, Mathur VS, Massumi A, Castro CMD, Garcia E, et al. Coronary artery anomalies: a review of more than 10,000 patients from the Clayton Cardiovascular Laboratories. Tex Heart Inst J. 1988;15(3):166-173.
  3. Engel HJ, Torres C, Page HL Jr. Major variations in anatomical origin of the coronary arteries: angiographic observations in 4,250 patients without associated congenital heart disease. Cathet Cardiovasc Diagn. 1975;1(2):157-169.
  4. Page HL Jr, Engel HJ, Campbell WB, Thomas CS Jr. Anomalous origin of the left circumflex coronary artery. Recognition, antiographic demonstration and clinical significance. Circulation. 1974 Oct;50(4):768-773.
  5. Chaitman B, Lesperance J, Saltiel J, Bourassa M. Clinical, angiographic, and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation. 1976;53(1):122-131.
  6. Ilia R. Percutaneous transluminal angioplasty of coronary arteries with anomalous origin. Cathet Cardiovasc Diagn. 1995;35(1):36-41.
  7. Hendiri T, Alibegovic J, Bonvini RF, Camenzind E. Successful angioplasty of an occluded aberrant coronary artery: A rare cause of acute myocardial infarction. Acute Card Care. 2006;8(2):125-127.
  8. Schwartz L, Aldridge HE, Szarga C, Cseplo R-M. Percutaneous transluminal angioplasty of an anomalous left circumflex coronary artery arising from the right sinus of valsalva. Cathet Cardiovasc Diagn. 1982;8(6):623-627.
  9. Topaz O, Disciascio G, Goudreau E, Cowley MJ, Nath A, Kohli RS, et al. Coronary angioplasty of anomalous coronary arteries: Notes on technical aspects. Cathet Cardiovasc Diagn. 1990;21(2):106-111.
  10. Kimbiris D, Lo E, Iskandrian A. Percutaneous transluminal coronary angioplasty of anomalous left circumflex coronary artery. Cathet Cardiovasc Diagn. 1987;13(6):407-410.
  11. Bass T, Miller A, Rubin M, Stowers S, Perryman R. Transluminal angioplasty of anomalous coronary arteries. Am Heart J. 1986;112(3):610-613.
  12. Rivitz SM, Garratt KN. Stenotic anomalous circumflex artery causing myocardial infarction following angioplasty of a right coronary artery stenosis. Cathet Cardiovasc Diagn.  1989;17(2):105-108.