A Case of Anomalous Origin of the Right Coronary Artery from the Left Anterior Descending Artery

A 34-year-old man, ex-smoker, with family history of coronary artery disease presented to the emergency room complaining of an episode of chest discomfort at rest, radiating to the arms, accompanied with palpitations, that started several hours earlier, lasted for several minutes and resolved with a syncopal episode. He did not mention any prior similar episodes and did not have angina or dyspnea on exertion, orthopnea or paroxysmal nocturnal dyspnea. At the time of presentation he was asymptomatic. His physical examination was unremarkable. However, his electrocardiogram revealed sinus rhythm with mild ST depression and T-wave inversion in leads I, avL, V4-V6. The patient was admitted to the coronary care unit with a possible diagnosis of an acute coronary syndrome. Cardiac markers remained normal in consecutive measurements. His echocardiogram was normal and a 24-hour Holter recording did not reveal any significant arrhythmic events. Coronary angiography was performed for further evaluation of the episode; it displayed normal courses of the left main coronary artery (LMCA), dominant left circumflex (LCX), and left anterior descending artery (LAD). An anomalous right coronary artery (RCA) as a separate small branch arose from the distal LAD with subsequent anterior course (Fig. 1 & 2)... (excerpt

Vanishing Collaterals Immediately Post-Percutaneous Coronary Revascularization

A 74-year-old gentleman with history of diabetes mellitus, hypercholesterolemia, tobacco use and prior myocardial infarction, was admitted via the emergency room due to unstable angina. He had sustained a lateral non-ST elevation myocardial infarction 6 years earlier, when he was submitted to percutaneous coronary intervention (PCI) and stenting of the obtuse marginal branch of the left circumflex coronary artery, considered the culprit lesion and during the same session, stenting was also performed of a stenosis of borderline angiographic significance of the left anterior descending (LAD) coronary artery. During his current admission, urgent coronary angiography was performed, which revealed a total proximal occlusion of the LAD (panel A, arrow); full collateral supply of the LAD was noted from the right coronary artery (panel B, arrows). A significant proximal lesion of the right coronary artery was also detected (not shown).The patient consented to an attempt to revascularize the occluded vessel via PCI, which was successfully accomplished with implantation of 3 coronary stents (panel C, thick arrow). Successful direct stenting was also performed of the proximal lesion of the right coronary artery. Upon completion of the PCI procedure, contrast injection of the right coronary artery revealed the disappearance of the collateral vessels supplied to the LAD (panel D, dashed arrows). Echocardiographic examination showed a near-normal systolic function of the left ventricle (ejection fraction ~55%)

Phantom Stent Thrombosis

Initial visualization of only the left circumflex coronary artery during coronary angiography in a 71-year-old patient with prior stenting of the left anterior descending (LAD) coronary artery would have led to an erroneous conclusion of a thrombosed stent and occluded coronary artery with its consequent management problems, before it was disclosed that the LAD originated from a separate ostium

Inordinately Sluggish Coronary Artery Flow in an Angiographically Normal Coronary Artery

A 53-year-old male smoker, without any significant medical history was admitted via the emergency room to the cardiac care unit due to a single episode of unstable angina lasting for approximately 10 minutes. Over the last one year he admits to symptoms indicative of CCS class II effort angina. He had a positive exercise stress test a year earlier. On admission no ischemic ECG changes were noted. Cardiac enzymes were normal. Coronary angiography, performed the next day, revealed no significant atherosclerotic lesions, however an impressively sluggish flow was observed in the left anterior descending (LAD) coronary artery. The patient was discharged home the following day on full antianginal regimen, including aspirin, clopidogrel, nitrates, β-blocker and statin. At three months later the patient has remained free of symptoms

Simplified swift and safe vascular closure device deployment without a local arteriogram: Single center experience in 2074 consecutive patients

Objective: Vascular closure devices (VCDs), such as the Angio-Seal, a three-component hemostatic plug, have greatly facilitated the routine clinical practice in the catheterization laboratory. The manufacturer recommends a local angiogram before Angio-Seal deployment. However, from the outset, we employed a simplified routine of deploying this VCD, i.e. without use of local angiography. Methods: The Angio-Seal was employed without a preceding femoral arteriogram over 8 years in 2074 consecutive patients, 72% presenting with acute coronary syndromes and subjected to coronary angiography (n = 1032) or PCI n = 1042) via a transfemoral approach with use of heparin and dual antiplatelet therapy. Results: Deployment of the VCD was successful in 99.4%. Complete hemostasis was obtained in 98% of cases. In 14 patients, Angio-Seal deployment failed. Mean time for placement of Angio-Seal was <1 min, to-hemostasis 1 min, and to-mobilization 3 h. Only 3 (0.15%) patients had a major complication with vessel occlusion that required emergent vascular surgery with a successful outcome. Two patients developed a local pseudoaneurysm treated with ultrasonography-guided compression. Six small and 4 large inguinal hematomas (one requiring blood transfusion) and 5 cases of retroperitoneal bleeding (one requiring blood transfusion) were recorded. Conclusion: Deployment of Angio-Seal without use of local angiography was efficacious and safe, characterized by a high success rate of deployment and hemostasis with few correctable complications in a large patient cohort undergoing transfemoral catheterization for PCI and non-PCI procedures under anticoagulation and antiplatelet drug therapy. VCD reduced the time-to-hemostasis and time-to-mobilization and minimized the incidence of complications