A really gruelling PTCA done in arogyasree patient in Poulami hoospitals all by myself got published in Journal of Invasive cardilogy http://www.invasivecardiology.com/articles/successful-angioplasty-anomalous-coronary-arteries-total-occlusions?page=2

1. PTCA of Total Occlusion of
Anomalous RCA using
Modified AL 2 catheter
Dr P Uday Prashant MD DM
Consultant Cardiologist
POULAMI HOSPITALS
Hyderabad
MD, DM

2. Introduction
• Isolated coronary anomalies occur 1% in general
population and incidence of RCA anomalies is 0.09%
• Medline search revealed only 4 isolated case reports
on PTCA of chronic total occlusion of anomalous RCA
• “ to the best of our knowledge, we report the first case
in the literature of successful coronary intervention in a
totally occluded anomalous RCA originating from the
left sinus of Valsalva” - Hideaki Kaneda, MD, PhD,
Saeko Takahashi, MD- Jan 2007; Journal of Invasive
Cardiology

3. Case History
• 34 yr old male smoker, alcoholic
• History of severe chest pain 3-4 mo back not
properly treated.
• Since then complaining of chronic stable
angina
• ECG shows e/o old Inferior wall MI.
• CAG on 1/9/2010 showed anomalous RCA
origin near left Sinus of valsalva with 100% cut
off & retrograde filling from left system

5. CAG
• By radial route did left system CAG
• But when encountered difficulty in RCA
cannulation changed to femoral
• Multiple unsuccessful attempts to cannulate
with JR, RR, AR catheters
• AL 2 6F catheter successful in cannulating
RCA.
• Procedure time took 2 hours with 250-300 ml
dye contrast.

10. FIRST ATTEMPT
• Taken up for elective PTCA after 3 days of
hydration.
• Kept on LMW heparin after CAG.
• AR1 guiding catheter engaged successfully
whereas AL 1 or AL 2 failed during first attempt.
• AL catheters couldn’t engage because the ostium
of anomalous RCA is directed inferiorly instead of
superior direction
• But AR catheter couldn't give enough support and
again due to prolonged procedure time and dye
constraint procedure abandoned

14. Newer techniques for anomalous RCA
total occlusions
• Deeper engagement guiding catheters,
• Tapered-tip guidewires - 0.009 cm tip
• Intravascular USG guided guide wires
• The five-in-six system or mother and child
technique - insertion of flexible tip cathter
• Penetration catheters- TORNUS, microcatheter
• The anchoring technique17 and
• The retrograde approach

15. • Ikari et al quantitatively measured the backup force of
guiding catheters for the right coronary artery.
• Three factors were found to be associated with the backup
force:
catheter size,
angle (theta) of the catheter on the reverse side
of the aorta and
the area of contact made by the catheter on
aorta4.
• The angle (theta) determines the force that can dislode the
guiding catheter.
In my case I felt if we could have proper guiding catheter it
would solve all the problems instead of resorting to
complicated techniques

16. Successful PTCA
• On 9/9/2010 patient was again taken for repeat
attempt of PTCA stent to RCA.
• Realized only AL catheter would give enough
support for successful PTCA even if other
catheters could cannulate RCA.
• But simple AL `s Primary curve not suitable to
intubate RCA and secondary not enough to
provide sufficient support
• So decided to shape catheter after taking aortic
root measurements

17. • The catheter was shaped outside gently by making
distal curve or primary curve straight so that it is more
co-axial to RCA ostium.
• The secondary curve is made very wide and elongated
so that it sits in Antero posterior diameter of root of
aorta and the opposite aortic wall provides backup
force during intervention
• Whisper wire used initially but was going into false
lumen with lot of resistance.
• So exchanged with BMW wire along with 1.5 * 10 mm
Sprinter balloon support and after lot of difficulty
crossed the CTO

30. Analysis of 24 pts among 40,000 CAG`s
with Anomalous RCA PTCA
• Type A was found in four patients; that is above the left Sino-tubular plane.
For three of them Forward Takeoff Judkins (FL) catheter successfully used
and one patient required Femoral Curved Left (FCL).
• Type B was in five patients; this is below the origin of LCA. In four cases
among five, FCL3.0 or 3.5 was successful.
• Type C was common and it was in nine patients; in which RCA originating
from between the LCA and the midline. At this originating point Voda Left
(VL) was successful in eight cases out of nine.
•
Type D was in just six cases, where anomalous RCA originating in or from
the midline of first and third lines. In this type of anomalous RCAs; Amplatz
Left 1 (AL1), Amplatz Left 2 (AL2) and Amplatz Left 3 (AL3) were used in
three, one and one patients respectively
Sarkar et al……

34. • Rahman and others [18] are the first to provide
solution for catheter selection based on
patient’s image data.
• They consider
the RCA curve length and curve angles
as well as catheter’s curve length and curve
angle
and suggest an optimal catheter for the RCA
based on these computations
Optimal catheter selection for anomalous Right Coronary Arteries (RCA) Usman Rauf This thesis is
presented as part of Degree of Master of Science in Electrical Engineering Blekinge Institute of technology
January 2011Blekinge Institute of Technology, School of Engineering University Supervisor:
Dr. Jörgen Nordberg

38. Conclusions
• PTCA to total occlusion of anomalous RCA is
not only technically challenging but also a
rare combination. Only 4 case reports
• Many of the difficulties in such situations can
be overcome initially by selecting appropriate
guiding catheter instead of going for more
complicated procedural techniques.

39. THANK YOU