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.
On the second
day after admission, coronary angiography was performed. Left coronary angiography revealed a short LAD originating from the LMCA, giving rise to proximal septal branches and the first diagonal artery (D1) (Figure
A). There was significant stenosis of the proximal portions of the short LAD and the D1, and there appeared to be total occlusion of the mid portion of the short LAD. The left circumflex artery originated normally from the LMCA and showed no significant stenosis. Right coronary angiography revealed a dominant RCA with a long LAD originating from its proximal portion (Figure
B). The RCA originated above the right coronary sinus and pointed downwards. The long LAD coursed left until turning downwards to the apex, giving rise to the second diagonal artery (D2) at the turning point. No bridging phenomenon was observed in systole in the traversing portion of the long LAD. There was significant stenosis of the mid portion of the long LAD, the proximal portion of the D2, the distal RCA and the proximal portion of the posterior descending artery.
Figure 1 Coronary angiography and percutaneous coronary intervention.A) Short LAD (long black arrow) originating from the LMCA, giving rise to the D1 (short black arrow). There is significant stenosis in the proximal portion of the short LAD and the proximal portion (more ...)
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
C). Xience Prime everolimus-eluting stents (Abbott Laboratories, Illinois, USA) were implanted in the distal RCA and the posterior descending artery (stent size 3.0
mm and 3.5
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
mm Ikazuchi balloon (Kaneka Medical Products, Nagoya, Japan) in the long LAD and the D2 (Figure
). 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
mm Xience Prime stent was implanted in the short LAD, crossing over the D1.
On the third day after admission, the patient underwent computed tomographic coronary angiography (CT-CAG) to determine the spatial relationships between the long LAD and the surrounding structures. It was found that the long LAD originated from the proximal RCA, coursed left between the aortic root and the RVOT then entered the mid anterior interventricular groove, where it gave rise to the D2. The long LAD did not run into the ventricular crest or the septum. The D2 was the dominant artery in the anterior wall of the left ventricle (Figure
Figure 2 Computed tomographic coronary angiography. (A) LAO cranial view showing the dual LAD anomaly with the short LAD on the proximal AIVG, giving rise to the D1 and the long LAD entering the mid AIVG giving rise to the D2. (B) LAO cranial view with the RVOT (more ...)
The patient was discharged without complications on the fifth day after admission.