A case report of type VI dual left anterior descending coronary artery anomaly presenting with non-ST-segment elevation myocardial infarction
© Lee et al.; licensee BioMed Central Ltd. 2012
Received: 8 July 2012
Accepted: 8 November 2012
Published: 13 November 2012
Type VI dual left anterior descending artery (LAD) is a rare coronary anomaly, the first case of which has recently been described. This is the first report of type VI dual LAD anomaly in which the patient presented with non-ST-segment elevation myocardial infarction and percutaneous coronary intervention was performed in the anomalously originating LAD.
A 52-year-old man with diabetes, hypertension and hyperlipidemia presented with chest pain without ST elevation on EKG, although the patient’s troponin I level was elevated. Coronary angiography revealed a short LAD originating from the left main coronary artery and a long LAD originating from the proximal portion of the right coronary artery (RCA). Three-dimensional reconstruction of computed tomography of images revealed that the long LAD originated from the proximal RCA and coursed between the right ventricular outflow tract (RVOT) and the aortic root before entering the mid anterior interventricular groove. The high take-off RCA originated underneath the RVOT, pointing downwards and forming an acute angle with the proximal portion of the long LAD. The anomalous long LAD displayed significant stenosis. We performed successful percutaneous coronary intervention (PCI) in the anomalous artery.
With accurate understanding of the coronary anatomy and appropriate hardware selection, successful PCI can be performed in the in the long LAD in patients with type VI dual LAD anomaly.
KeywordsType VI dual LAD anomaly Percutaneous coronary intervention Computed tomographic coronary angiography
Accurate assessment of the coronary anatomy is crucial for successful percutaneous coronary interventions (PCI) in anomalously originating coronary arteries. Type VI dual left anterior descending artery (LAD), recently reported by Maroney et al. , is an anomaly in which a short LAD originates from the left main coronary artery (LMCA) and a long LAD originates from the right coronary artery (RCA). The long LAD passes between the right ventricular outflow tract (RVOT) and the aortic root. We report a case of type VI dual LAD anomaly presenting with non-ST-segment elevation myocardial infarction in which PCI on the anomalous long LAD was successfully performed.
A 52-year old man with hypertension, type 2 diabetes and dyslipidemia presented with sustained chest pain. Electrocardiography showed flattened T waves in lateral and inferior leads and the patient’s serum troponin I was increased. Echocardiography showed inferior wall hypokinesia with preserved left ventricular ejection fraction. The patient was diagnosed with non-ST-segment elevation myocardial infarction and was admitted to the coronary care unit.
PCI was performed using a right trans-radial approach with a 6-French sheath. Deep engagement with a Multipurpose (MP) guiding catheter (Cordis Corporation, Bridgewater, NJ, USA) was required to deliver a balloon and stents through the downward-oriented RCA ostium (Figure 1C). Xience Prime everolimus-eluting stents (Abbott Laboratories, Illinois, USA) were implanted in the distal RCA and the posterior descending artery (stent size 3.0 × 24 mm and 3.5 × 24 mm, respectively). Successful balloon angioplasty was performed with a Judkins right (JR) 4.0 guiding catheter (Cordis Corporation, Bridgewater, NJ, USA) and a 2.5 × 20 mm Ikazuchi balloon (Kaneka Medical Products, Nagoya, Japan) in the long LAD and the D2 (Figure 1D). The procedure was terminated at this point because of concern about the difficulty of delivering a stent through the acute angle between the proximal RCA and the traversing portion of the long LAD with poor guiding catheter support. Finally, a Judkins left 4.0 guiding catheter (Cordis Corporation, Bridgewater, NJ, USA) was used in the short LAD and a 3.0 × 28 mm Xience Prime stent was implanted in the short LAD, crossing over the D1.
The patient was discharged without complications on the fifth day after admission.
Classification of dual left anterior descending coronary arteries []
Course of long LAD*
Epicardial course on the LV side of the proximal AIVG, reentering the distal AIVG
Epicardial course on the RV side of the proximal AIVG, reentering the distal AIVG
Septal and diagonal
Intramyocardial course in the proximal septum, then either emerging epicardially in distal AIVG or terminating intramyocardially as septal branches.
1. Epicardial course anterior to the RVOT continuing to the distal AIVG
Septal and diagonal
2. Intramyocardial course within septal crest emerging epicardially in the distal AIVG
Intramyocardial course within the septal crest emerging epicardially in the distal AIVG
Septal and diagonal
Epicardial course between the RVOT and the aortic root, continuing to the mid or distal AIVG
Septal and diagonal
It is difficult to determine the course of an anomalous coronary artery using angiography alone, especially when the anomalous artery passes between the great vessels or through the myocardium . CT-CAG can be a powerful tool in assessing spatial relationships between an anomalous coronary artery and surrounding structures [6, 7]. In this case, CT-CAG was useful in determining the course of the long LAD. The reconstructed images, from which the RVOT was removed, showed that the long LAD passed between the RVOT and the aortic root without taking an intramyocardial course (Figure 2B).
Unlike the previous case, our patient underwent PCI. Although the MP and the JR 4.0 guiding catheters were suitable for coaxial positioning with the downward-pointing RCA and the traversing portion of the long LAD, they did not provide good support. Deep intubation as used in this case is one way to improve the backup force in transradial interventions . Alternatively, a buddy wire technique, buddy balloon technique, different choice of guiding catheter, or transfemoral approach could improve support [9, 10].
In summary, type VI dual LAD is a recently recognized rare anomaly in which the long LAD courses between the RVOT and the aortic root, potentially leading to negative clinical consequences. CT-CAG can provide spatial information on the relationship between long LAD and the neighboring structures. Successful PCI can be performed safely in this type of anomaly with accurate assessment of the coronary anatomy and appropriate selection of hardware.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the Series Editor of BMC Cardiovascular Disorders.
Percutaneous coronary intervention
Left anterior descending artery
Right coronary artery
Right ventricular outflow tract
Left main coronary artery
First diagonal artery
Second diagonal artery
Computed tomographic coronary angiography.
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