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Coronary Stenting for a Chronic Total Occlusion of Right Coronary Artery in a Situs Inversus Patient

- Operator: Seung-Jung Park, MD

Patient presentation

A 50-year old man was admitted with stable angina for 6 months. He took coronary stenting with a TAXUS stent in proximal left anterior descending artery (LAD) in other hospital 1 year ago. His chest radiograph showed the presence of a right sided stomach gas bubble and a right sided aortic knuckle confirming situs inversus (Image 1). He had diabetes mellitus and hypercholesterolemia as coronary risk factors.

Procedure

His right femoral artery was accessed with a 7Fr guiding sheath. The anatomical left coronary system (right sided) was cannulated with a 6Fr AL1 catheter. The angiogram showed patent stent in proximal LAD with intermediate narrowing of middle LAD [Image 2, AP caudal view; Image 3, equivalent LAO cranial view (RAO view)]. The anatomical right coronary artery was also cannulated with a 6Fr AL1 catheter and the angiogram showed chronic total occlusion of proximal RCA [Image 4, equivalent LAO view (RAO view)]. We planned a PCI and 7Fr AL1 guiding catheter was engaged at RCA ostium But, a test shot showed stasis of contrast along the RCA revealing coronary dissection (Image 5). A 0.014 inch Choice PT wire was successfully passed through the lesion and the lesion was serially predilated with a 1.5 x 20 mm Maverick balloon (1.5 mm, 6 atm) and a 3.0 x 20mm Sprinter balloon (3.18 mm, 12 atm). Then, three Cypher stents were sequentially deployed in the proximal RCA (3.5 x 33 mm up to 3.72mm, 16 atm, Image 6), the distal RCA (3.0 x 13 mm up to 3.21 mm, 16 atm, Image 7) and the middle RCA (3.0 x 33 mm up to 3.21 mm, 16 atm, Image 8). Adjunctive high pressure balloon dilation was followed with a 3.5 x 20mm Sprinter balloon up to 3.8 mm (14 atm, Image 9). The final angiogram showed a successful result (Image 10).

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