Coronary angiography and percutaneous intervention in anomalous aortic coronary origin: a challenge in the cathlab

Abstract Introduction Anomalous aortic origin of coronary arteries (AAOCA) is a rare type of congenital malformation, estimated in 0.35% - 2.1% of general population, associated with sudden cardiac death. Anomalous origin presents technical challenges for the interventionalist in diagnostic and therapeutic procedures, data in this context is limited. Purpose We aimed to describe characteristics of coronary angiography and percutaneous intervention (PCI) in patients with AAOCA. Methods In this retrospective and observational study at a national reference center, all coronary angiographies and PCI performed from January 2012 to December 2023 were eligible for review. Demographic features and angiographic/interventional data were identified and reviewed from electronic medical records. Results We identified 204 patients with AAOCA in whom coronary angiography and/or PCI were performed. Most frequent was right coronary artery (RCA) from Left sinus of Valsalva (LSV) (N=83, 41%) followed by Circumflex artery from Right sinus of Valsalva (RSV) (N=40, 20%), RCA from ascending Aorta (AA) (N= 34, 17%), RCA from sinotubular junction (N= 24, 12%), Left main coronary artery (LMCA) from RSV (N=9, 5%), LMCA from AA (N=4, 2%), RCA from Non coronary sinus of Valsalva (NCSV) (N=3, 1.5%), anterior descending artery from AA (N=2, 1%), LMCA from sinotubular junction (N=2, 1%) and LMCA from NCSV (N=1, 0.5%). Mean age was 58.72 ± 12.04 years, 67.6 % were men, most frequent indication of procedure was chronic coronary syndrome and elective procedure most frequently as pre cardiac surgery protocol. Right transradial access site was the most used, selective cannulation of AAOCA was possible in 96.08% patients, crossover to femoral due to impossibility to canulate AAOCA was 1.47% (N=3, RCA from RSV and RCA from AA), nonselective contrast injection due to failure to cannulate anomalous coronary origin was performed in RCA from RSV and AA. Mean number of diagnostic catheters were 2.32 ± 0.8, fluoroscopy time was 17:47 ± 13:36 and contrast volume used was 227 ± 93 mL. RCA from LSV had the most fluoroscopy time (18:36 ±12:53) and contrast volume used (140.58 mL ±92). In 26 AAOCA PCI was performed, in just one case (RCA from sinotubular junction) there was failure to complete PCI by impossibility to canulate and advance PCI guidewires, mean number of guide catheters was 1.24 ± 0.6, contrast volume was 243.5 ± 112 mL, median fluoroscopy time was 26:38 (17:00 – 41:49) and radiation exposure was 2855.50 mGy (2075.75 – 6006). RCA from AA presented the greatest fluoroscopy time, radiation exposure and contrast volume. Conclusions Coronary angiography and PCI in AAOCA are difficult technical procedures, with high use of contrast, fluoroscopy time and radiation exposure. RCA from sinotubular junction and above are the most difficult aortic origin to cannulate. However, successful procedure can be achieved in most patients with careful selection of diagnostic and guide catheters.