Endovascular therapy for congenital coronary artery anomalies in adults

Abstract

Coronary artery anomalies (CAAs) may be discovered more often as incidental findings during standard diagnostic workup for other cardiac diseases or less frequently on the basis of manifestations of myocardial ischaemia. Interventional cardiologists may be involved in their angiographic diagnosis, functional assessment and eventual endovascular treatment. Complete angiographic definition is essential in order to assess functional status and plan the appropriate intervention: computed tomography and magnetic resonance imaging are useful, non-invasive tools for detecting three-dimensional morphology of the anomalies and its relationship with adjacent cardiac structures, whereas coronary arteriography remains the gold standard for a definitive anatomic picture. A practical idea of the possible functional significance is mandatory for deciding how to manage CAAs: non-invasive stress tests and, in particular, invasive pharmacological stress tests with or without intravascular ultrasound monitoring can correctly assess the functional significance of most CAAs. Finally, the knowledge of the particular endovascular techniques and material is of paramount importance for achieving technical and clinical success. In this brief review, the authors have focused their attention on the interventional techniques to treat various CAA subtypes, with reference to angiographic diagnosis and functional assessment.

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

“…[1191][1192][1193][1194] The method of revascularization employed in adults with anomalous coronary arteries has been 1) CABG or, more recently, 2) PCI with stenting. 1195 When CABG is employed, consideration should be given to the presence of competitive flow in the native coronary circulation. 1196 In children and some adults, an unroofing procedure or coronary arterial reimplantation may provide the best long term results.…”

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

“…Isolated case reports of other coronary arterial anomalies in subjects with syncope or sudden death emphasize the need for careful anatomic and functional evaluation of all individuals with anomalous coronary arteries (1191)(1192)(1193)(1194). The method of revascularization employed in adults with anomalous coronary arteries has been 1) CABG or, more recently, 2) PCI with stenting (1195). When CABG is employed, consideration should be given to the presence of competitive flow in the native coronary circulation (1196).…”

Is endovascular therapy the right choice for treatment of functional compression of anomalous right coronary artery arising from left coronary sinus with interarterial course?

“…Difficult cannulation, suboptimal backup support with standard GCs owing to the ectopic juxtacommissural ostium and tangential direction of the anomalous vessels adds to the procedural complexities and increases procedural time. Appropriate GC selection and choosing extra support guidewires and using balloon catheter support to facilitate guidewire advancement are some of the technical considerations that need merit during PCI to right-ACAOS 33. Switching from one access route to another (femoral to radial/brachial or vice versa), use of large GC like Amplatz GC (AL2,3), unusual GC-like Champ catheter or venous bypass GC, use of moderately stiff guidewires like PT (Boston Scientific, Minnesota, USA) can be tried in difficult situations 33.…”

“…Appropriate GC selection and choosing extra support guidewires and using balloon catheter support to facilitate guidewire advancement are some of the technical considerations that need merit during PCI to right-ACAOS 33. Switching from one access route to another (femoral to radial/brachial or vice versa), use of large GC like Amplatz GC (AL2,3), unusual GC-like Champ catheter or venous bypass GC, use of moderately stiff guidewires like PT (Boston Scientific, Minnesota, USA) can be tried in difficult situations 33. We have been using a simple technique using JL GC, which has been well described in the literature, to hook the right ACAOS during PCIs for this vessel with an excellent technical success rate 34…”