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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 53-55  

A rare case of “acute take off” of left circumflex artery successfully intervened using dual-lumen microcatheter


Department of Cardiology, TNMC and BYL Nair Ch. Hospital, Mumbai, Maharashtra, India

Date of Web Publication31-Jul-2019

Correspondence Address:
Dr. Digvijay Deeliprao Nalawade
18-ICCU, Department of Cardiology, Ground Floor, OPD Building, Nair Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_72_18

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   Abstract 


“Acute take off” of the left circumflex artery (LCX) is a rare coronary artery variant. Development of coronary artery disease in such a vessel increases technical difficulty and failure rate for percutaneous coronary intervention. We report a rare case of “acute take off” of the LCX with proximal critical stenosis successfully intervened using dual-lumen microcatheter.

Keywords: Coronary artery disease, left circumflex artery, percutaneous coronary intervention


How to cite this article:
Chaurasia AS, Nawale JM, Nalawade DD. A rare case of “acute take off” of left circumflex artery successfully intervened using dual-lumen microcatheter. Heart Views 2019;20:53-5

How to cite this URL:
Chaurasia AS, Nawale JM, Nalawade DD. A rare case of “acute take off” of left circumflex artery successfully intervened using dual-lumen microcatheter. Heart Views [serial online] 2019 [cited 2019 Dec 6];20:53-5. Available from: http://www.heartviews.org/text.asp?2019/20/2/53/263852




   Introduction Top


Angelini et al. in 2008 first reported “acute take off” of the left circumflex artery (LCX) as a coronary anatomic variant which angiographically features ≤45° angle between the left main trunk and LCX in two orthogonal, caudal projections. It is associated with longer left main trunk than that seen in general population (24.9 vs. 9.8 mm, respectively).[1] The reported incidence is 2%. Although rare, it has potential clinical consequences and imposes technical difficulties for performing percutaneous coronary intervention (PCI).[1],[2] Dual-lumen microcatheters are generally used for managing bifurcation lesions. Our case report highlights difficulties faced and successful use of dual-lumen microcatheter for intervening such diseased vessel.


   Case Presentation Top


A 56-year-old gentleman, hypertensive, diabetic presented with complaints of rest angina for 1 h. His electrocardiogram showed ST-T changes in inferolateral leads with raised cardiac enzymes. Routine blood investigations and two-dimensional echocardiography were normal. He was diagnosed as a case of non-ST elevation myocardial infarction and was initially managed conservatively. Later, he underwent coronary angiography followed by an attempt of PCI for lesion in LCX, which was unsuccessful. After one more unsuccessful PCI attempt at yet another hospital, the patient was referred to us.

Review of angiograms revealed a co-dominant circulation with an acutely angled LCX wherein the angle between left main and LCX was 40°–42° with long (22 mm) left main [Figure 1]a and [Figure 1]b. LCX had proximal 95% discrete stenosis followed by 80% long-segment lesion with thrombolysis in myocardial infarction II flow distally; ramus had proximal long-segment 80% stenosis, and other vessels were normal [Figure 1]a. It was found that during the initial two attempts, operators were not able to cross the LCX lesion leading to procedural failure.
Figure 1: Cine angiographic views demonstrating “acute take off” of the LCX with percutaneous intervention using dual-lumen microcatheter. (a) RAO caudal view showing 40.3° angle between left main stem and LCX. LCX has proximal 95% discrete stenosis followed by 80% long-segment lesion with TIMI II flow distally, ramus has proximal 80% long segment stenosis. (b) LAO caudal view showing 42.8° angle between left main stem and LCX. (c) RAO caudal view showing Crusade (Kaneka), dual lumen microcatheter used to cross LCX lesion with two radiopaque markers, the distal marker represents the central lumen exit port while the proximal marker represents over the wire lumen exit port. The microcatheter positioned such that central lumen coronary guidewire, Sion (Asahi Intecc) is in ramus and over the wire lumen coronary guidewire Fielder (Asahi Intecc) is crossed into LCX. (d) RAO caudal view showing successful post-stenting results with two stents in LCX and one in ramus with TIMI III flow distally. (Measurements done by QCA analysis software; LAO: Left anterior oblique, LCX: Left circumflex artery, RAO: Right anterior oblique, TIMI: Thrombolysis in myocardial infarction)

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In view of recurrent episodes of angina, the patient was planned for PCI using right femoral route. Initial attempts to cross the LCX with hydrophilic coronary guidewires were unsuccessful. Acute angle of LCX made it very difficult for guidewire to cross, and even with balloon support, the entire assembly would prolapse into unintended adjacent branches.

Hence, it was decided to use dual-lumen microcatheter Crusade (Kaneka) to increase guidewire support. Ramus lesion was initially crossed using Sion (Asahi Intecc), and then, Crusade was advanced over it using its central monorail port [Figure 2]a and was positioned in such a way that its proximal over the wire (OTW) exit port radiopaque marker faced the ostium of LCX [Figure 1]c and [Figure 2]b confirmed in two orthogonal, caudal positions. This facilitated crossing of LCX lesion with hydrophilic polymer coated wire Fielder (Asahi Intecc) which was passed through OTW lumen [Figure 1]c and [Figure 2]c after giving >90° tip curve. Further steps were done conventionally with resultant successful deployment of two stents in LCX (proximal 3.00 mm × 28 mm everolimus-eluting stent, Synergy [Boston Scientific] and distal 2.5 mm × 16 mm everolimus-eluting stent, Promus Element [Boston Scientific]) and one in ramus (2.75 mm × 32 mm everolimus-eluting stent Promus Element [Boston Scientific]) [Figure 1]d. A Few days later, the patient was discharged without any complications.
Figure 2: Schematic illustration of steps for negotiating “acute take off” left circumflex artery using dual-lumen microcatheter. (a) The dual lumen microcatheter through its central monorail port advanced over the hydrophilic guidewire Sion (Asahi Intecc) in the ramus. (b) Positioning of microcatheter in such a way that the over the wire exit port faces towards LCX ostium. (c) Successful crossing of LCX lesion with hydrophilic polymer coated coronary guide wire Fielder (Asahi Intecc) through over the wire lumen after giving proximal >90° ;curve to its tip. (LCX: Left circumflex artery)

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   Discussion Top


There are many conventional methods for manipulating guidewire into an extremely angled side branch such as improving guide catheter support, changing the wire to more stiff or hydrophilic type, making a wire tip curve of >90°, and utilizing balloon for increasing wire support. Many of these were tried in our case but found unsuccessful.

Crusade (Kaneka) is a double-lumen multifunctional 2.9 Fr microcatheter designed for use in bifurcation lesions.[3],[4] Guidewire in the monorail lumen protruding from the end helps to stabilize it, while guidewire in the OTW lumen protruding from the side hole can be directed toward ostium of intended branch.[3],[4] Crusade has two radiopaque markers: the distal-most represents central lumen exit port, while the proximal marker represents OTW lumen exit port [Figure 1]c. For crossing LCX lesion, microcatheter was positioned in such a way that central lumen coronary guidewire, Sion was in ramus with OTW exit port facing toward LCX ostium. Keeping the wire in ramus helped us to achieve the desired position after which microcatheter provided adjunctive support for Fielder to cross the LCX lesion through OTW lumen [Figure 1]c, stents were deployed in LCX and ramus smoothly in a conventional manner [Figure 1]d.


   Conclusion Top


“Acute take off” of the LCX, though a rare coronary anatomic variant, should be recognized as a difficult case for PCI. Although the reported experience and literature is limited; the use of dual-lumen microcatheter may facilitate the procedure by providing additional support to the guidewire in desired position to negotiate the intended lesion. Its use is simple and reliable, decreases quantity of hardware used and fluoroscopic time, and also increases chances of procedural success.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Angelini P, Trujillo A, Sawaya F, Lee VV. “Acute takeoff” of the circumflex artery: A newly recognized coronary anatomic variant with potential clinical consequences. Tex Heart Inst J 2008;35:28-31.  Back to cited text no. 1
    
2.
Wilensky RL, Selzer F, Johnston J, Laskey WK, Klugherz BD, Block P, et al. Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI dynamic registry). Am J Cardiol 2002;90:216-21.  Back to cited text no. 2
    
3.
Chiu CA. Recanalization of difficult bifurcation lesions using adjunctive double-lumen microcatheter support: Two case reports. J Invasive Cardiol 2010;22:E99-103.  Back to cited text no. 3
    
4.
Oreglia JA, Garbo R, Gagnor A, Gasparini GL. Dual lumen microcatheters for complex percutaneous coronary interventions. Cardiovasc Revasc Med 2018;19:298-305.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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