catheter selection for coronary angiography and intervention in anomalous right coronary arteries

C©2009, the AuthorsJournal compilation C©2009, Wiley Periodicals, Inc.

DOI: 10.1111/j.1540-8183.2009.00463.x

Catheter Selection for Coronary Angiography and Interventionin Anomalous Right Coronary Arteries

KUNAL SARKAR, M.D., SAMIN K. SHARMA, M.D., F.A.C.C.,

and ANNAPOORNA S. KINI, M.D., M.R.C.P., F.A.C.C.

From the Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, New York

Background: An anomalous origin of the right coronary artery (ARCA) from the left sinus of Valsalva (LSOV) hasbeen reported in 6–27% of patients with coronary anomalies. The unusual location and course of this anomalyposes a technical challenge for the interventionalist. Appropriate guiding catheter selection is critical to ensuresuccessful angiography and percutaneous intervention (PCI). We report our experience in 24 patients with ananomalous RCA originating from the LSOV.Methods: Twenty-four angiograms of ARCA-LSOV were reviewed by two independent interventionalists withattention to the origin and take off of the RCA within the aortic root. The origin was adjudicated with a schemebased on anatomical landmarks as described—A: origin from the aorta above the sinotubular plane; B: originjust below the ostium of the left coronary artery (LCA); C: origin below the sinotubular plane between the midlineand the LCA; D: origin along the midline.Results: The distribution of various takeoffs of the RCA was as follows: For type A (N = 4) the FL3.0 and FCL3.0catheters were successful in three and one cases, respectively. For type B (N = 5) the FCL3.0 or 3.5 was successfulin four out of the five cases. For type C (N = 9) the VL catheter was successful in eight (VL3.5 = 5:VL 3.0 = 3)cases. The AL catheter was successful in five cases of type D (N = 6) RCAs (AL1 = 3:AL2 = 1:AL3 = 1).Conclusions: The classification method and catheter selection provide a useful framework to successfully engageARCA-LSOV and may reduce contrast and radiation exposure. (J Interven Cardiol 2009;22:234–239)

Introduction

Coronary arteries of anomalous origin are uncom-mon and encountered in 0.2–1.2% of patients undergo-ing percutaneous coronary intervention and representa marked deviation of the normal anatomic pattern.1,2

Coronary vessels develop prior to the formation ofthe arterial orifices in the aortic sinuses: it is nowthought that the vessels arise by vasculogenesis,3 andthat mesenchymal cells in the subepicardial space giverise to primitive vessels that invade the myocardium

There is no conflict of interest either real or perceived of any authorin the publication of this manuscript.

Address for reprints: Samin K. Sharma, M.D., F.A.C.C., CardiacCath Lab and Intervention, Mount Sinai Hospital, Box 1030, OneGustave L. Levy Place, New York, NY 10029. Fax: (212) 534-2845;e-mail: [email protected]

and spread over the myocardial surface.4 Sprouts ofthis plexus approach the base of the outflow tractand connect to the sinuses of the aortic root.5,6 Ul-timately, only solitary right and left coronary arter-ies remain and eventually acquire a medial wall andan adventitial covering. The mature coronary vascularpattern is established by remodeling of the capillaryplexuses and reduction in the number of arteriovenousanastomoses. Experimental evidence links the occur-rence of coronary anomalies with an abnormal migra-tion of neural crest cells.7,8 An anomalous origin ofthe right coronary artery (RCA) from the left sinusof Valsalva (LSOV) has been reported in 6–27% ofpatients with coronary anomalies. The reported inci-dence of this finding in various angiographic seriesof consecutive patients from various centers has var-ied between 0.02 and 0.17%.9 Anomalous RCA hasalso been documented to originate from the pulmonary

234 Journal of Interventional Cardiology Vol. 22, No. 3, 2009

CATHETER SELECTION FOR ANOMALOUS RIGHT CORONARY ARTERIES

artery, left ventricular outflow tract, left main coro-nary artery, aorto-left ventricular canal, noncoronarysinus of Valsalva, and from above the sinus of Val-salva. The presence of this anomaly may be associ-ated with an increased predisposition to developingsignificant epicardial atherosclerotic disease.10 Occa-sionally one does encounter patients in late adult-hood who present with an anomalous right coronaryartery and angiographically significant atheroscleroticdisease.

The unusual location and course of this anomalyposes a considerable technical challenge to the inter-ventionalist. It requires a systematic approach to theevaluation of coronary anatomy and distribution in or-der to avoid complications. In particular, the selectionof an appropriate guiding catheter is critical to en-sure selective angiography, proper assessment of lesioncharacteristics, and facilitate successful delivery of ap-propriate devices. We report our institutional experi-ence with angiography and percutaneous intervention(PCI) in a series of 25 patients who were found to havean angiographically significant lesion requiring PCI inan RCA that originated either from the LSOV or justabove the left sinotubular plane.

Methods

Mount Sinai Hospital Interventional Database.A prospective interventional database is maintainedat the Mount Sinai Hospital under the aegis of anInstitutional Review Board approved protocol. Thedatabase includes demographic, clinical, laboratory,angiographic, and procedural data. Records of imme-diate and in-hospital events are maintained and all pa-tients continue receiving telephonic follow-up period-ically. Our institution is a tertiary referral center withspecial expertise in complex coronary interventions.Between March 2003 and November 2007, a total of25 patients (N = 25) underwent PCI for an angiograph-ically significant lesion in a right coronary artery of ananomalous origin in the LSOV. The angiograms wereretrieved from our institutional archive and reviewedby two independent interventional cardiologists withspecific attention to the origin and takeoff of the RCAwithin the aortic sinus.

The origin of RCA was adjudicated based on theprespecified classification scheme that has been de-scribed below. The femoral approach was used inall cases. Procedures performed included balloon an-

gioplasty, cutting balloon angioplasty, and stent de-ployment. A single nonionic contrast agent, iopami-dol (Isovue, Bracco Diagnostics), was used almostexclusively for these procedures. All diagnostic an-giograms were performed with 6Fr catheters. Sheathsize was upgraded to 7Fr as necessitated by angio-graphic findings prior to the start of the PCI procedure.After angiography of the left coronary system an ini-tial attempt was made to engage the right coronaryartery in the left anterior oblique (LAO) projectionusing the Judkins 4 (JR) right catheter. If successfulengagement of the RCA could not be obtained usingJR catheter, a test injection was given in the aorticroot (hand injection aortogram) to visualize the originof the RCA in the 30–35◦ LAO projection. The aor-togram was helpful in defining the shape and size ofthe aorta, and showing the position and orientation ofthe right coronary ostium. This facilitated the selectionof appropriate coronary catheters for engagement ofthe anomalous RCA. Coronary catheter selection wasmade after study of the cine loop of the aortogram withparticular emphasis on the origin and orientation of theRCA. Based on the review of the LAO aortogram, weidentified four common areas of the origin of RCAfrom and around the left sinus of Valsalva. We haveorganized our angiographic observations in the formof a simplified classification scheme that is describedbelow.

Classification Scheme (Fig. 1). In the LAO view,the outflow tract of the left ventricle and aorta mayschematically be regarded as a cylinder with a bulge inthe middle owing to the presence of aortic sinuses.An imaginary line drawn at the upper edge of thebulge marks the plane dividing the aortic sinuses fromthe ascending aorta. A similar line drawn along thelower edge of this bulge divides the aortic cusps fromthe ventricular outflow tract. Finally, a line is drawnalong the long axis of the ascending aorta intersectingthe sinus aortic and aortoventricular planes perpen-dicularly (p-p′). The origin of the anomalous vesselis described based on its location in relation to theselandmarks:

A: Origin from the aorta above the sinotubular plane.B: Origin just below the ostium of the left coronary

artery (LCA).C: Origin below the sinotubular plane between

the midline and the origin of left coronaryartery.

D: Origin along the midline.

Vol. 22, No. 3, 2009 Journal of Interventional Cardiology 235

SARKAR, ET AL.

Figure 1. Origin of anomalous RCA fromLSOV. Representative diagram of aortic rootand sinuses in LAO projection. p-p′ indi-cates a hypothetical plane running throughthe midline. Sites A through D representcommon sites for the origin of the anoma-lous artery and correspond with the classifi-cation system represented in Figure 1.

Results

A total of 42,346 procedures including 8,776 PCIswere performed at the Mount Sinai Hospital during theperiod from March 2003 through November 2007.Outof these, 25 patients with an anomalous origin of theRCA from LSOV who underwent PCI were identified.In cases where a patient underwent multiple procedureson the same vessel, we included only the first PCIinto our analysis. There was interobserver agreementin all but one case where the observers could not agreeif the actual takeoff the anomalous artery was in theLSOV or an anterior takeoff in the right sinus. This wasattributed to an inadequate opacification of the root inthe aortogram. The vessel was engaged successfullywith an AL1 guide catheter. This case was howeverexcluded from further analysis. Hence, a total of 24angiograms were analyzed for the origin and the guidecatheter successful in cannulating the RCA for PCI.Only two cases had a diagnostic coronary angiogramperformed at another facility prior to their presentationat our Institution.

The results are presented in Figure 2. Type A take-off of the RCA (above the left sinotubular plane,Figure 3A) was found in four cases. Type B take-off (below the origin of LCA) was seen in five cases(Figure 3B). Type C was the most common variantof anomalous RCA observed in our series with theRCA originating between the LCA and the midline innine cases (Figure 3C). An anomalous RCA originat-ing in or near the midline (type D) was seen in sixcases (Figure 3D). For type A takeoffs the FL (for-ward takeoff Judkins left guide) 3.0 (Boston Scien-tific, Maple Grove, Minnesota) catheter was success-

ful in three cases, while FCL (femoral curved left) 3.0was successful in one case. For type B takeoffs, theFCL3.0 or 3.5 (Boston Scientific, Maple Grove, Min-nesota) was successful in four out of the five cases.In contrast, the VL (Voda left) catheter was success-ful in eight (VL3.5 = 5:VL3.0 = 3) out of the ninetype C takeoffs in our series. Finally, the AL (Amplatzleft) catheter was successful in cannulating all but onecase of type D anomalous RCAs (AL1 = 3:AL2 =1:AL3 = 1). Table 1 shows the sequence of catheterstried (starting with the JR4 catheter) and the catheterthat provided stable engagement for PCI. In addition,the fluoroscopic time and contrast expenditure also de-creased progressively with continued experience andevolution in our technique.

Discussion

Successful percutaneous treatment of stenotic le-sions in ARCA-LSOV has been reported infrequentlyin the literature mostly in the form of small case se-ries.11–13 A variety of guiding catheters have been usedand advocated. These include Judkins left catheter (JL)and its longer and shorter variants14 as well as Amplatzleft catheter (AL1 and AL2).15 A modification of theAL1 consisting of a right angled deviation of the tip(Leya catheter) has also been used successfully in somecases.16 To our knowledge, this is the largest series ofsuch cases reported in literature. We have presentedour institutional experience in approaching this condi-tion in the form of a integrative classification schemebased on anatomic landmarks in a standard angio-graphic projection. A number of angiographic factors



Figure 2. Distribution of coronary catheters for selective coronary angiography and PCI of anomalous RCA based on the site of origin in theaortic sinuses of Valsalva. RCA = right coronary artery; VL = Voda left; AL = Amplatz left; FCL = femoral curve left; JR = Judkins right.

such as the dimensions of the aortic root, the desiredlevel of backup support, configuration of the ostium,initial trajectory, angle at takeoff, location of the lesion,and the type of device to be used are important aspectsthat influence the selection of a guide catheter. Prob-lems are encountered during therapeutic proceduresdue to an inadequate alignment of the guide catheter

Figure 3. Engagement of ARCA-LSOV. A through D illustrate the different takeoffs of anomalous RCA from LSOV and their successfulengagement with guiding catheters in LAO 30–35◦ projection. Type A through D takeoffs are most likely to be successfully engaged with FL,FCL, VL, and AL catheter shapes, respectively.

with the initial course of the artery. Figure 4 illustratesthe catheter curves we have used to cannulate the dif-ferent variants of ARCA-LSOV. For anomalous RCAoriginating above the left sinus of Valsalva just adjacentto the LCA, the FL catheter with a smaller secondarycurve than the one used to cannulate the left coronaryostium was successful in providing engagement for


SARKAR, ET AL.

Table 1. Summary of 24 Cases of PCI in Anomalous RCA Originating from LSOV. The Type of Takeoff, Sequence of Catheters Tried, andthe Successful Catheter for Engagement as Well as the Contrast and Fluoroscopy Time for Each Case Have Been Presented. Of Note Is the

Reduction in the Number of Catheters Used in Each Case, Total Radiation, and Contrast Expenditure with Evolution in Technique

Patient Type of Successful Total Total FluoroscopyNo. Takeoff Sequence of Catheters Catheter Contrast (mL) Time (Minutes)

1 A JR 4:FL3:FL3.5:FCL3 FCL3 250 402 C JR 4:FL3.5:VL3:FCL3.5 FCL3.5 270 453 D JR 4 JR4 210 504 C JR 4:FCL4:FCL3.5:VL3 VL3 260 405 D JR 4:FL3.5:VL3.5:AL1 AL1 200 456 D JR 4:VL3:VL3.5:AL2 AL2 250 507 A JR 4:FCL3.5:FL3.5:FL3 FL3 210 528 C JR 4:FCL4:VL3:VL3.5 VL3.5 240 489 C JR 4:FCL4:VL3:VL3.5 VL3.5 200 44

10 B JR 4:FL4:FCL3 FCL3 200 3811 A JR 4:FCL3:FL3.5:FL3 FL3 200 3212 D JR 4:FCL4:AL1:AL1 AL1 180 2813 B JR 4:FCL3.5:FCL4:VL3 VL3 170 3014 D JR 4:VL3.5:AL1:AL1 AL1 180 2515 A JR 4:FL3 FL3 160 2816 B JR 4:FCL3.5:FCL3 FCL3 140 2217 C JR 4:FCL4:VL3 VL3 145 2418 C JR 4:VL3.5:VL3 VL3 130 2819 B JR 4:FL3.5:FCL3.5 FCL3.5 120 2220 C JR 4:FCL4:VL3.5 VL3.5 110 2421 C JR 4:VL3.5 VL3.5 120 2622 B JR 4:FCL3.5 FCL3.5 120 2423 C JR 4:VL3.5 VL3.5 110 2524 D JR 4:AL2:AL3 AL3 120 24

the anomalous RCA. The FL catheter has a secondaryradius of curvature that is slightly smaller than a cor-responding JL catheter. This allows the guide catheterto act as a hook and engage an RCA originating abovethe LCA at an angle and then coursing inferiorly and tothe right. The FCL catheter curve (known as Q curvefor dilated aortic root) was most successful in engag-ing type B RCA ostia. The enhanced curve of the FCL

Figure 4. Common guiding catheter shapes used for ARCA-LSOV. FCL curve, Q curve (FCL for large aortic root size), Voda (VL), forwardtakeoff Judkins (FL), and standard Judkins (JL) catheters are represented.

catheter sits well in the aortic root and affords goodsupport for RCAs originating just below the LCA.The VL catheter was most likely to succeed in pro-viding engagement and good backup for anomalousRCAs that originate between the midline and borderof the left coronary sinus below the sinotubular plane.In comparison with an FCL curve, the curvature ofa Voda catheter allows it to assume a horizontal and



Table 2. Guiding Catheters from Different Manufacturers withSimilar Curves That Can be Used to Engage ARCA-LSOV

Boston Guidant/Scientific Medtronic Cordis ACS

Left CLSTM (FCL) EBU Curves R© XB/XB GLCoronary LADCurves Voda left R© (VL) EBU Curves R© XB GL

Q CurveTM JCL XB LAD JCLFL JL (Sherpa JL JL

NX), FL

downward-pointing configuration in the aortic root thatprovides a large area of support and optimal alignmentfor this particular location of the artery. The Amplatzleft (AL) catheter was the catheter of choice for en-gaging aberrant RCA that originates from the midlineof the aortic root. The AL catheter is useful in en-gagement of RCAs that have anterior or horizontaltakeoff in the right sinus of Valsalva. It is intuitivethat a type D origin of an anomalous RCA is similarto an anterior takeoff albeit in the left coronary sinus.Importantly, we found a correlation between the guid-ing catheter that was most likely to be successful inengaging the ostium and the actual point of origin ofthe aberrant artery. It needs to be reiterated that thereexists a pronounced learning curve and our catheteri-zation protocol has evolved over the last 3 years witha reduction in fluoroscopy and procedure time withincreased experience. In addition to other anatomicfactors, catheter selection for PCI is also influencedto a certain degree by operator preference, familiarity,and institutional availability. The catheter shapes wehave used are commonly used and widely availablein most laboratories. There are other guide cathetersfrom different manufacturers used in clinical practice(Table 2) that may be reasonable choices for engaginganomalous RCAs provided the unique anatomic char-acteristics and landmarks that we have discussed areintegrated into the catheter selection process. Whereaseach individual case may require a slightly differentapproach, we believe that the classification method de-scribed here provides a simple and effective frameworkfor the busy interventionalist to successfully engage theanomalous vessel with reduced expenditure of contrast

agent and radiation exposure, thus increasing the like-lihood of technical success.

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catheter selection for coronary angiography and intervention in anomalous right coronary arteries

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