This was an 82-year-old woman who presented to us one month ago with non-Q-wave inferior myocardial infarction. She was known to have hyperlipidemia and coronary heart disease with percutaneous coronary stenting performed in the left anterior descending (LAD) and anomalous right coronary arteries (RCA) nine years ago.

Procedure

Diagnostic catheterization using 6F AL I revealed a 90% stenosis in mid-RCA distal to the previously implanted GR 2 stent (Figure 1). There was mild to moderate in-stent restenosis in RCA and LAD (Figure 2). The RCA originated from left coronary sinus close to left main artery and had an inferior take-off. Coaxial engagement of guiding catheters (AL 1, MP 2, EBU 4.5) at the anomalous RCA was unsuccessful. The 6F EBU 4.5 catheter tip was at right angle to the vessel wall. We used a BMW Universal guidewire (0.014 in, 300 cm) with Transit catheter support to cross the lesion. We disengaged the guiding catheter from RCA after successful wiring to allow a portion of guidewire to form a smooth curve between catheter tip and RCA ostium. After pre-dilatation with Voyager (2.0 x 20 mm), Endeavor (2.75 x 24 mm at 14 atm) was deployed at the culprit lesion. Both the balloon and stent could be easily tracked along the curve and down to the lesion (Figure 3). The final angiogram showed good stent expansion and TIMI 3 flow (Figure 4).