Percutaneous Coronary Intervention of Hidden Coronary Artery-Unusual Type of Isolated Single Coronary Artery

Abstract

A 55-year-old woman presented to the Emergency Department with typical angina of 4 hours duration. Patient was diagnosed as having acute coronary syndrome-acute Inferoposterior wall myocardial infarction. Patient had past history of hypertension, diabetes mellitus, dyslipidemia and hypothyroidism for last five years for which she was on following medication: Telmisartan 40mg once daily, glimepride 1mg once daily, thyroxin 25mg once daily. Patient had no family history of coronary artery disease.Initial physical examination revealed, heart rate of 62 beats per minute, blood pressure of 110/70mmHg, and was otherwise unremarkable. An Electrocardiogram (ECG) revealed a normal sinus rhythm with Inferoposterior wall myocardial infarction. A two dimensional echocardiogram revealed LV segmental hypokinesia and an ejection fraction of 40%. Patient was immediately treated with thrombolytic therapy. As patient had failed thrombolysis by persistent angina and unresolved ST segment by ECG, hence, rescue PCI was considered. Coronary angiography was performed which revealed LCx total occlusion and RCA could not be cannulated [Table/ Fig-1,2]. Hence, anomalous origin was suspected and proceeded with PTCA to LCx, pending Computed Tomography Coronary Angiogram (CT CAG) to identify origin of RCA. During PTCA when LCx was predilated, interestingly it was noted that RCA was arising from distal LCx (single coronary artery was noted). Right coronary artery also had 90% stenosis at the site of origin from distal LCx (RCA was hidden within occluded LCx which also had critical lesion). After predilatation of LCx, Keywords: Biventricular dysfunction, Inferior wall myocardial Infarction, Left circumflex artery ABSTRACTSingle coronary artery is a rare congenital coronary artery anomaly, the incidence of which is 0.024-0.066% as described in literature. Report of cases having single coronary artery along with acute myocardial infarction are scanty and reports of percutaneous intervention in such a situation are even fewer, technically challenging and potentially cataclysmic. As single coronary artery supplies the entire myocardium, occlusion of this can result in significant ischemic insult, resulting in severe biventricular dysfunction. Percutaneous Coronary Intervention (PCI) of single coronary artery is technically challenging and carries high risk which may be equated to left main intervention. We report a rare interesting case of L1 variety of single coronary artery which presented as acute inferoposterior myocardial infarction with successful rescue PCI to Left Circumflex Artery (LCx).

Anomalous origin of the right coronary artery from the proximal segment of the left circumflex artery combined with acute myocardial infarction: a rare type L II-P single coronary artery

“…However, SCA might contribute to the development of myocardial ischemia due to the relatively small proximal vessel, which may either become diseased or cause distal coronary arterial lesions to become more hemodynamically significant by reducing coronary blood flow, such as through resistance in series ( 17 ). Furthermore, SCA occlusion impairs the blood supply to almost the entire myocardium, possibly resulting in severe biventricular dysfunction ( 23 ). An anomalous coronary artery originating from the opposite coronary artery or coronary sinus of Valsalva between the aorta and the pulmonary artery is associated with increased risks of myocardial ischemia and sudden death in younger patients during exercise ( 16 ).…”