# Multimodality imaging and advanced calcium treatment to facilitate PCI in a rare coronary artery anomaly—case report

## TL;DR

A rare coronary artery anomaly in a 76-year-old man was treated using advanced imaging and calcium treatment to guide a complex heart procedure.

## Contribution

The case highlights the use of multimodal imaging and intravascular lithotripsy in managing PCI for a rare coronary anomaly.

## Key findings

- CT coronary angiography and IVUS provided critical guidance for PCI in a patient with a rare coronary artery anomaly.
- Intravascular lithotripsy was effective in treating extensive calcification prior to stent implantation.
- Drug-coated balloon treatment successfully addressed restenosis six months after the initial procedure.

## Abstract

Coronary artery anomalies (CAAs) are a rare congenital condition and represent additional challenges in interventional treatment of coronary artery disease.

A 76-year-old male, was admitted for elective coronary angiography due to symptoms of typical angina. CT coronary angiography (CTCA) revealed all three coronary arteries arising from the right sinus of Valsalva, where right coronary artery (RCA) and left anterior descending artery (LAD) had common ostium with significant stenosis of ostio-proximal RCA and circumflex artery (CX) coming from a separate one. Percutaneous coronary intervention (PCI) of ostial RCA was planned and intravascular ultrasound (IVUS) in both RCA and LAD was done. Due to extensive calcification, prior to intended PCI, intravascular lithotripsy (IVL) was done. Following IVL and extensive predilatation drug eluting stent (DES) was implanted. Final IVUS was used to confirm optimal stent deployment in proximal RCA and to verify that LAD ostium was not compromised with RCA stent. Six months later, due to angina and positive stress test, repeated coronary angiography revealed a restenosis of the ostial RCA so the lesion was again treated with drug-coated balloon with optimal procedural results.

Although rare, CAAs could be associated with coronary artery disease and usually present additional challenge for interventional treatment. Advanced imaging modalities, including CTCA and IVUS, provide good procedural guidance during complex PCI procedures in patients with CAAs.