The document reports on two cases of successful percutaneous coronary intervention on anomalous right coronary arteries originating from the left coronary sinus. In both cases, the Voda guiding catheter was able to selectively engage the anomalous arteries, allowing for stenting of significant lesions. The Voda catheter provided stable support due to its shape and location opposite the left coronary ostium. Percutaneous intervention of anomalous coronary arteries requires careful planning and catheter selection. In these cases, the Voda catheter facilitated successful revascularization.

1. Brief Report
Indian Heart J 2001; 53: 000–000
Percutaneous Transluminal Coronary Angioplasty with
Stenting of Anomalous Right Coronary Artery Originating
From Left Sinus of Valsalva Using the Voda Guiding
Catheter: A Report of Two Cases
Tarun K Praharaj, Gautamananda Ray
B.M. Birla Heart Research Centre, Calcutta
Coronary arteries of anomalous origin are uncommon and some forms seem to be predisposed to atherosclerosis.
We report two cases of successful stent implantation in an anomalous right coronary artery originating from
the left sinus of Valsalva using the Voda guiding catheter. (Indian Heart J 2001; 53: 79–82)
Key Words: Coronary anomalies, Angioplasty, Stents
C
oronary arteries of anomalous origin are uncommon
and found in only 0.2%–1.2% of patients undergoing
percutaneous transluminal coronary angioplasty
(PTCA).1–3 Anomalous origin of the right coronary artery
(RCA) from the left sinus of Valsalva (LSOV) has been found
in 6%–27% of patients with coronary anomalies4 and in
0.02%–0.17% of coronary angiogram. 5 Although
clinically thought to be a benign anomaly, it can cause
angina pectoris or myocardial infarction even in the absence
of any distinct atherosclerotic lesion.6 At times, it can lead
to faintness, ventricular fibrillation and sudden cardiac
death. 7 Anomalies cause technical problems during
coronary angiography as well as during PTCA. There are
few reports of PTCA of anomalous coronary arteries.8–12
We report two cases of successful stenting of anomalous
RCA originating from the LSOV using the Voda guiding
catheter.
anterior to the left main coronary artery and took a caudal
anterior course between the great vessels before it continued
on its normal course into the right atrioventricular groove.
The left ventricular function was normal with a left
ventricular ejection fraction (LVEF) of 64% . The anterior
location of the ostium in the left coronary cusp with
tortuous proximal portion of the artery with its caudal
anterior course posed specific problems for cannulation.
Diagnostic right coronary angiogram was done using a left
Amplatz II catheter (Fig. 2) and anomalous origin of RCA
from the LSOV was observed. The patient was re-admitted
2 weeks later for PTCA of the RCA because he remained
Case Report
Case 1: A 53-year-old male was admitted to our center with
a clinical diagnosis of crescendo angina of recent onset.
Coronary angiography revealed 70%–80% long segment
stenosis (16 mm) of the mid-RCA. The left circumflex and
the left anterior descending artery were free from any
disease. The 3 mm diameter-sized RCA was anomalous and
originated from the LSOV (Fig. 1). The anomalous RCA lay
Correspondence: Dr Tarun K Praharaj, Senior Consultant Cardiologist,
B.M. Birla Heart Research Centre, Library Avenue, Calcutta 700027
e-mail: bmbrc@birlaheart.com
IHJ-876-00.p65
79
Fig. 1. Left coronary sinus injection in left anterior oblique (LAO) view which
faintly shows the origin of the anomalous RCA from the left coronary sinus.
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2. 80 Praharaj et al.
Indian Heart J 2001; 53: 79–82
Stenting of Anomalous Right Coronary
Fig. 2. Right coronary angiogram was done using a left Amplatz Catheter in
LAO view showing severe long segment stenosis in the mid-RCA.
Fig. 4. Right coronary angiogram in LAO view showing the inflated balloon.
Fig. 3. Right coronary angiogram in LAO view showing left Voda guiding
catheter deeply engaged in the RCA with its tip well seated in the mid ostium.
Fig. 5. Final diagnostic angiogram following stenting.
symptomatic despite medical treatment. The artery could
not be cannulated even after using different catheters
including the Amplatz catheter. Finally, the RCA was
selectively cannulated by Voda Left 8 F guide catheter (inner
lumen diameter 0.080", Boston Scientific Corporation,
Minnesota) (Fig. 3). The RCA stenotic lesion was successfully
crossed with a 0.014" Hi-torque intermediate wire
(Advanced Cardiovascular System, Califorina), and dilated
with a 3×20 mm Rocket balloon (Advanced Cardiovascular
system, California) (Fig. 4). After predilatation of the
narrowed segment, a 3×18 mm MultiLink stent (Advanced
Cardiovascular System, California) was deployed at 16 atm.
A final diagnostic angiogram showed an excellent
angiographic result (Fig. 5). The immediate post-procedure
IHJ-876-00.p65
80
stay of the patient was uneventful and he was discharged
three days later on regular calcium channel blockers,
aspirin and ticlopidine (for 6 weeks). The patient continued
to remain asymptomatic with a good quality of life on oneyear follow-up.
Case 2: A 56-year-old male presented with a clinical
diagnosis of effort angina of recent onset with diabetes and
hypertension. His coronary angiography revealed a normal
left main coronary artery and left anterior descending
artery. However, the left circumflex artery was a small
caliber vessel, totally occluded in its mid-segment and filled
through collaterals from the left anterior descending artery.
Mid-RCA had a 70%–80% long segment narrowing with
subtotal occlusion in its distal segment. The distal RCA was
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3. Indian Heart J 2001; 53: 79–82
Praharaj et al.
Stenting of Anomalous Right Coronary
81
Fig. 6. Left coronary sinus injection in left anterior oblique view showing the
origin of the anomalous RCA from the LSOV.
Fig. 8. Right coronary angiogram in LAO view showing the inflated balloon.
Fig. 7. Right coronary angiogram done using left Voda guiding catheter in
LAO view showing long segment stenosis in the mid-RCA and subtotal occlusion
of the distal RCA.
Fig. 9. Right coronary angiogram in LAO view showing the final diagnostic
angiogram.
seen to be filled through collaterals from the left anterior
descending artery. The RCA (3 mm diameter) originated
from the LSOV (Fig. 6) and passed between the pulmonary
artery and aorta to reach the right atrioventricular groove.
Thereafter it followed a normal course. The LVEF by twodimensional echocardiography was 52%. There was mild
hypokinesia of the inferior wall. The anomalous RCA had
an ostium located anteriorly and superiorly and could not
be cannulated with Judkin, Multipurpose and Amplatz
catheters. However, cannulation was easily possible with a
Voda 8 F guiding catheter (Fig. 7). The long segment
narrowing in mid-RCA and the subtotally occluded distal
RCA were successfully crossed with a 0.014" Hi-torque
intermediate wire and dilated with a 3×20 mm Rocket
balloon. The lesion in the mid-RCA was successfully dilated
at 10 atm and the distal segment was stented after
predilatation, using a 3×15 mm MultiLink stent at 16 atm
(Fig. 8). The final diagnostic angiogram revealed excellent
result (Fig. 9). A totally occluded left circumflex artery was
successfully crossed with a 0.014" Hi-torque intermediate
wire and predilated using a 2.5×20 mm balloon and a 2.5×
15 mm MultiLink stent was deployed at 12 atm with good
angiographic result. The immediate post-procedure stay of
the patient was uneventful and the patient was discharged
on regular medications. He remained asymptomatic at
follow-up after 7 months.
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4. 82 Praharaj et al.
Discussion
PTCA in patients with an anomalous RCA is technically
challenging. It demands a high degree of awareness, and
complete evaluation of the coronary artery anatomy and
distribution in order to avoid complications. The
complication rate of coronary arteriography and PTCA is
related to the duration of the procedure. Topaz et al.11 have
described various aspects of orifice configuration, anatomy
of the artery, location of atherosclerotic lesions and also
guiding catheter selection. Proper guiding catheter selection
decreases procedure time in PTCA involving anomalous
coronary arteries and thus increases success rate. In both
cases, we were able to cannulate the anomalous RCA using
the Voda guiding catheter. In the first case, the initial
angiography was done using the left Amplatz catheter.
However, during PTCA, the cannulation was not possible
with the Amplatz catheter. Use of the Voda guiding catheter
in both cases provided easy cannulation with enough backup support. The choice of the Voda guiding catheter was
based on its curvature, large area of support and location
of the artery just opposite to the left ostium. It provided the
maximum stable support required for the smooth passage
of the balloon as well as the stent. The tip of the catheter
sits well in the anomalous vessel and the secondary curve
rests stably against the opposite aortic wall. The anatomical
course of the anomalous RCA in both our cases corresponds
to the course described by Ilia.13 Usually, the anomalous
RCA originating from the LSOV almost invariably follows a
similar course.5 Thus, it appears that the Voda guiding
catheter may be the best for PTCA of a coronary artery with
similar anomaly.
Several techniques have been reported for PTCA in an
anomalous RCA.5, 11–14 However, we could cannulate the
anomalous RCA in both our cases with relative ease and
got good back-up support using the Voda guiding catheter.
Thus, after careful study of the course of the anomalous
artery, location of the lesion and selective use of the Voda
guiding catheter, angioplasty and stenting can be performed
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Indian Heart J 2001; 53: 79–82
Stenting of Anomalous Right Coronary
82
in patients with an anomalous RCA originating from the
LSOV with excellent results.
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