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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3735_Библиотеки_им_академика_М_И_Перельмана
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F. Bedogni
Anomalous LCx fromtheRight Cusp
Anomalous LCx from the right coronary sinus
associated with a retro-aortic course has a prevalence of 0.3% and is usually considered as a
benign anomaly. However, in case of aortic valve
replacement surgery, it may make the surgical
procedure more difcult since it can be complicated with closure of the LCx. This anomaly may
also have an impact on TAVI procedures, since
there is a risk of compression due to the TAVI
valve. In this scenario, a balloon angioplasty of
the aortic valve may precede TAVI in order to
screen for that risk. In the latter case, a selfexpanding valve is the rst choice over a balloon
expandable valve. An alternative strategy is to
have a guidewire placed into the coronary artery
and have a bail-out stent available.
The preferred projection to show this anomaly
is the right anterior oblique (RAO) 30° view. The
ideal catheter to show the anomaly is the Amplatz
left or right catheter, Judkins 4 right, and hockey
stick. A major detail to be kept in mind is that if
the catheter is too deep into the RCA then the
anomaly cannot be demonstrated. Therefore, it is
useful to place a guidewire in the distal RCA and
then play with a second guidewire in order to get
access to the difcult position of the LCx
(Figs.11.8, 11.9, and 11.10).
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a
b
c
Fig. 11.8 Transcatheter aortic valve in a patient with
anomalous left circumex coronary artery from right coronary artery Ref [1]. (a) Anomalous circumex from right
cusp retro aortic course engaged with Judkins right cath-
eter. (b) Aortogram pre-transcatheter aortic valve replacement. (c) Aortogram post-transcatheter aortic valve
replacement (Sapien S3) demonstrating risk for compression of the anomalous artery by a prosthetic valve
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F. Bedogni
a
b
c
Fig. 11.9 Anomalous left circumex coronary artery (LCx) from right cusp engaged with (a) Amplatz right catheter.
(b) Multipurpose catheter. (c) Computed tomographic imaging of anomalous LCx for right cusp with retro-aortic course
ab
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Fig. 11.10 Catheterization technique of how to engage
anomalous circumplex artery from right coronary artery
Ref [1]. (a) Image of the right coronary artery (RCA) with
Judkins right seated deep, missing the ostium of anomalous left circumex coronary artery (LCx). (b) Using
hockey stick guide and coronary wire in distal RCA to
stabilize the guide and pulling back the guide close to the
ostium, and a second guidewire used to direct the wire to
an anomalous LCx with a selective image
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F. Bedogni
Fig. 11.11 Left main coronary artery origin at the posterior of the left cusp Ref [1]. (a) Computed tomographic
image. (b) Angiographic view engaged with Judkins right
catheter. L left coronary cusp, NC noncoronary cusp, R
right coronary cusp
Posterior Origin oftheLeft Main
fromtheLeft Cusp or
NoncoronaryCusp
This anatomy is rare but can be difcult to selectivate. The ideal is to use guiding catheters as
EBU or CLS (Figs. 11.11 and 11.12).
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a
b
143
Fig. 11.12 Left main coronary artery origin from noncoronary cusp. Ref [1]. (a) Computed tomographic image.
(b) Angiographic view engaged with Judkins right cathe-
Anomalous Left Main Coronary
Artery fromtheRight Cusp
This anomaly occurs in up to 0.7% of the population and can have inter-arterial, septal (subpulmonic), retro-aortic, or anterior-pulmonic course.
A selective angiography is performed by
using a hockey stick or a right Judkins coronary
ter. L left coronary cusp, NC noncoronary cusp, R right
coronary cusp
catheter curve 4. The ideal angiographic projection is the RAO with caudal angulation view.
Sometimes placing a Swan-Ganz catheter in the
main pulmonary artery may help locate the
position and course of the coronary artery in
relationship to the pulmonary artery and the
aorta (Figs. 11.13, 11.14, 11.15, 11.16, and
11.17).
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F. Bedogni
a
b
c
Fig. 11.13 Angiographic views to identify left main
course from the right cusp Ref [1]. Right anterior oblique
caudal views of (a) left main coronary artery going up ante-
rior to pulmonary artery, (b) left main coronary artery down
posterior to pulmonary artery, and (c) left main coronary
artery straight in between the aorta and pulmonary artery
Fig. 11.14 Computed tomographic images Ref [1]. (a)
Caudal view left main coronary artery straight between
the aorta and pulmonary artery and (b) left anterior
descending coronary artery going up anterior to pulmonary artery, left circumex coronary artery down posterior
to aorta. RAO 1/4 right anterior oblique
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a
b
c
d
Fig. 11.15 Identify left main course with pulmonary
artery catheter in place Ref [1]. (a) Caudal view showing
left main coronary artery and Swan-Ganz but unable to
tell if in between pulmonary artery and aorta. (b) Lateral
view 90 with Swan-Ganz in the pulmonary artery showing
left main coronary artery in between aorta and pulmonary
artery. (c) CT image showing left main coronary artery in
between aorta and pulmonary artery diving down with
intraseptal course. (d) Computed tomographic lateral
view 90, same projection as angiography in (b)
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F. Bedogni
Fig. 11.16 Computed tomography and angiography of
left main coronary artery between the pulmonary artery
and aorta diving down through the crista supraventricular
is (within the ventricular septum beneath the right ventricular infundibulum) Ref [1]
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a
b
d
c
Fig. 11.17 Anomalous left main coronary artery from
the right cusp Ref [1]. (a) Angiography shows left anterior
descending coronary artery (LAD) anterior to pulmonary
artery. (b) Computed tomography (CT) shows LAD ante-
Anomalous Coronary Arteries
Originating fromtheOpposite
Sinus ofValsalva (ACAOS)
ACAOS are quite rare occurring in 0.26% of the
general population (03% for left coronary
ACAOS: L-ACAOS, 0.23% for right coronary
ACAOS: R-ACAOS) [2, 3]. There are several
risk factors associated to ischemic events in these
anomalies: they include a) slit-like ostium; b)
acute take-off angle; c) an intramural course; d)
inter-arterial course (Fig.11.18),
rior to pulmonary artery. (c) Angiography shows left circumex coronary artery (LCx) retro-aortic. (d) CT shows
LCx retro-aortic
(a) Slit-like ostium at the anomalous ostium is
dened as a≥50% reduction of the minimal
lumen diameter compared to the normal distal reference diameter [5] [<50% = oval
ostium [5]].
(b) Acute take-off angle (below 45°), dened as
an axial course of the proximal segment tangential to the great vessel circumference [6,
7], In this anatomical situation, exercise
leads to expansion of the aortic root, which
may decrease the acute take-off angle and
consequently increased narrowing at the
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