Successful Multivessel Coronary Interventions in a Patient With Single Coronary Artery

A 67-year-old man presented to hospital with chest pain. ECG revealed giant negative T waves in leads I, aVL, and V_1–6 with elevated cardiac troponin I (3.5ng/mL). Coronary angiography revealed severe stenosis of the mid-left anterior descending artery (LAD) with TIMI grade 2 flow (Figure A), moderate stenosis of the mid-left circumflex artery (LCX) (Figure B), and collateral circulation supplying the right coronary artery (RCA) (Figure B). The RCA could not be cannulated, and left ventricular angiography revealed ostial chronic total occlusion (CTO) (Figure C). The patient underwent emergency percutaneous coronary intervention (PCI) with SYNERGY stent implantation for severe LAD stenosis (Figure D). Coronary computed tomography angiography (CTA) performed later confirmed an absent RCA (Figure E) and CTO of the large LCX, which supplied the territory of the RCA through its terminal extension (Figure F). Therefore, the patient was diagnosed with a rare type of a single coronary artery (SCA; Lipton’s type L-IA). One month after the index PCI, staged PCI was performed on the LCX-CTO lesion (Figure G, Supplementary Movie 1), which was passed using the parallel wire technique, and a 2.5/32 mm SYNERGY stent was successfully deployed with resultant TIMI grade 3 flow (Figure H, Supplementary Movie 2). Furthermore, we observed that the RCA originated from the distal LCX. In the general population, the incidence of SCA is only 0.024–0.066%.

Figure.

Coronary angiograms showing severe stenosis of the mid-left anterior descending artery (LAD) with TIMI grade 2 flow (A, yellow arrows), moderate stenosis of the mid-left circumflex artery (LCX) (B, blue arrow), and collateral circulation supplying the right coronary artery (RCA) (B, yellow arrow). Left ventricular angiogram showing ostial chronic total occlusion (CTO) (C, yellow circle). The patient underwent emergency percutaneous coronary intervention (PCI) with SYNERGY stent implantation for severe LAD stenosis (D). Coronary computed tomography angiogram showing absent RCA (E, yellow circle) and CTO of the large LCX, which supplied the territory of the RCA through its terminal extension (F, blue arrows). One month after the index PCI, staged PCI was performed on the LCX-CTO lesion (G, blue arrows). A 2.5/32 mm SYNERGY stent was successfully deployed with resultant TIMI grade 3 flow (H, yellow dotted line).

We report a rare case of successful multivessel PCI in a patient with SCA. Coronary CTA is a useful minimally invasive diagnostic and therapeutic strategy for coronary artery anomalies, including SCA. In daily practice, SCA with an origin of the RCA from the LCX is an extremely rare finding. The main importance of SCA resides in the difficulties in diagnosis during coronary angiography. Therefore, physicians should consider the existence and anatomic types of this congenital anomaly.

Supplementary Files

Supplementary Movie 1. LCX-CTO lesion on coronary artery angiography.

Supplementary Movie 2. Post-stenting angiography.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-21-0128