Introduction

Anomalies of the coronary arteries affect about 1% of the general population, however its prevalence may range from 0.3 to 5.6% in reports of patients undergoing coronary angiography, can be detected in 1% of the routine necropsies.¹ Anomalous origin of the right coronary artery from the left sinus of Valsalva or interarterial is a rare congenital abnormality with a prevalence of 0.025 to 0.25%.² We present here the first case report of a patient with anomalous origin of the right coronary artery underwent elective percutaneous coronary intervention with bio-absorbable vascular scaffolds (BVS).

Case report

Male, 71 years of age, history of smoking, diabetes mellitus type 2 and hypertension, both of long evolution.

He began with typical angina at rest, being evaluated with 3 hours of symptoms onset, the diagnosis ST-segment elevation myocardial infarction in inferior wall was integrated, being a candidate for thrombolysis with tenecteplase, presenting reperfusion criteria. He was sent to our institution, being received out-time for pharmacoinvasive strategy, with hemodynamic stability.

At 72 hours maintains hemodynamic stability and stratification is performed with perfusory scintigraphy (technetium 99m-sestamibi) reporting inferior severe ischemia. At 96 hours of symptoms onset a transradial coronary angiography was performed, registering the left coronary system without angiographic lesions and normal distal flow (Figure 1), dominant right coronary artery with anomalous origin in the left side region of the ascending aorta, inter-arterial, between aorta and pulmonary artery, circumferentially traveling through the posterior wall of the ascending aorta, with an angiographic significant lesion in the middle segment and a maximum narrowness site of 70% (Figure 2), requiring an elective percutaneous coronary intervention (PCI), advancing universal guide to the posterior descending artery with subsequent evaluation of the lesion with optical coherence tomography (OCT) (Figure 3).­ After determining the characteristics balloon pre-dilatation was made with a 3 x 20 mm balloon in the mid-proximal segment. A BVS Absorb 3.5 x 28 mm was sailed in the middle segment and joined in proximal segment with BVS Absorb 3.5 x 23 mm, post-dilatating with 3.5 x 15 mm non-compliant balloon (Figure 4), posterior review with OCT showing an adequate expansion of the scaffolds, without complications or events (Figure 5). Discharged 24 hours after the procedure, it was performed a coronary tomography for further evaluation of placed BVS showing permeability of the right coronary artery (Figure 6). ­ Maintaining asymptomatic after six months of follow-up.

Figure 1: Diagnostic coronary angiography of the left system with no significant angiographic lesions with normal distal flow. 

Figure 2: Angiography of aorta in left anterior oblique projection. The anomalous origin of the right coronary artery in the anterolateral region of the ascending aorta (A). Coronary angiography of the right system showing a significant stenosis in the proximal and middle segment of the right coronary artery (B). 

Figure 3: Comparative diagram by segments between right coronary angiography and intracoronary OCT. A segment of the artery with significant angiographic lesion that correlates with a lipid plaque with diffuse and undefined edges with disruption and a total length of 21.7 mm. 

Figure 4: Coronary angiography in left anterior oblique projection at the time of delivery in the right coronary with an Absorb BVS 3.5 x 28 mm (A), then an Absorb BVS 3.5 x 23 mm (B) and control angiography (C). 

Figure 5: Comparative diagram by segments between right coronary angiography and intracoronary OCT obtained after delivery and post-dilation of both BVS, where appropriate apposition and increase of the luminal diameter intracoronary is observed. 

Figure 6: Multiplanar reformatted multidetector CT of coronary arteries. Showing the origin of the right coronary artery in the anterolateral region of the ascending aorta following the posterior wall of the aorta with inter-arterial rise. 

Discussion

The BVS born after two decades of continuous learning in stent technology. Since its association with anticoagulation schemes to the current dual antiplatelet regime, supported by intravascular imaging studies, there have been progressively acceptable results.³ Until the advent of drug-eluting stents (DES), which in the long term showed other behavior, specifically with vascular remodeling and other problems previously non-conceived as the difficulty or inability to perform coronary bypass (CABG) in extensive coronary territories treated via endovascular.⁴ Because of all the past experience the bio-absorbable technology emerged. These stents restore the coronary vasomotion at 12 months, facilitate the vessel remodeling, restore cyclic pulsatility in the implantation site and recover the lumen with plaque regression between 2-5 years after implantation.⁵ The first ABSORB study opened possibility for increasing use, provided that the optimum conditions for its implementation were present.⁶

The ABSORB III trial⁷ which compared BVS with DES (Everolimus), reported no-inferiority between BVS and DES after 1 year of implantation in rates of angina, complete revascularization and revascularization of culprit vessel but no statistically significant changes in mortality and incidence of myocardial infarction. These results have been reported similarly in other trials.⁸ Subacute thrombosis was more prevalent in BVS in the European register GHOST-EU,⁹ although not consistently observed in other studies.¹⁰

The use of BVS has been recently approved in coronary lesions with a length equal to or less than 24 mm, with a minimum diameter of reference vessel greater than 2.5 mm and not more than 3.75 mm. The experience with BVS in arteries with an anomalous origin is very limited,¹¹ and in Mexico non previously existent until this case.